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High burden of take a look at the site here antibiotic-resistant Mycoplasma genitalium in symptomatic urethritisMycoplasma genitalium 100mg viagra for sale is an aetiological agent of sexually transmitted urethritis. A cohort study investigated M. Genitalium prevalence, antibiotic resistance and association with previous macrolide exposure among 1816 Chinese men who presented with symptomatic 100mg viagra for sale urethritis between 2011 and 2015. was diagnosed by PCR, and sequencing was used to detect mutations that confer resistance to macrolides and fluoroquinolones. In 11% 100mg viagra for sale of men, M.

Genitalium was the sole pathogen identified. Nearly 90% 100mg viagra for sale of s were resistant to macrolides and fluoroquinolones. Previous macrolide exposure was associated with higher prevalence of resistance (97%). The findings point to the need for routine screening for 100mg viagra for sale M. Genitalium in symptomatic men with urethritis.

Treatment strategies to 100mg viagra for sale overcome antibiotic resistance in M. Genitalium are needed.Yang L, Xiaohong S, Wenjing L, et al. Mycoplasma genitalium 100mg viagra for sale in symptomatic male urethritis. Macrolide use is associated with increased resistance. Clin Infect Dis 2020;5:805–10.

Doi:10.1093/cid/ciz294.A new entry inhibitor offers promise for treatment-experienced patients with multidrug-resistant HIVFostemsavir, the 100mg viagra for sale prodrug of temsavir, is an attachment inhibitor. By targeting the gp120 protein on the HIV-1 envelope, it prevents viral interaction with the CD4 receptor. No cross-resistance 100mg viagra for sale has been described with other antiretroviral agents, including those that target viral entry by other modalities. In the phase III BRIGHTE trial, 371 highly treatment-experienced patients who had exhausted ≥4 classes of antiretrovirals received fostemsavir with an optimised regimen. After 48 weeks, 54% of those with 1–2 additional active drugs achieved viral load 100mg viagra for sale suppression <40 copies/mL.

Response rates were 38% among patients lacking other active agents. Drug-related adverse 100mg viagra for sale events included nausea (4%) and diarrhoea (3%). As gp120 substitutions reduced fostemsavir susceptibility in up to 70% of patients with virological failure, fostemsavir offers the most valuable salvage option in partnership with other active drugs.Kozal M, Aberg J, Pialoux G, et al. Fostemsavir in adults 100mg viagra for sale with multidrug-resistant HIV-1 . N Engl J Med 2020;382:1232–43.

Doi. 10.1056/NEJMoa1902493Novel tools to aid identification of hepatitis C in primary careHepatitis C can now be cured with oral antiviral treatment, and improving diagnosis is a key element of elimination strategies.1 A cluster randomised controlled trial in South West England tested performance and cost-effectiveness of an electronic algorithm that identified at-risk patients in primary care according to national recommendations,2 coupled with educational activities and interventions to increase patients’ awareness. Outcomes were testing uptake, diagnosis and referral to specialist care. Practices in the intervention arm had an increase in all outcome measures, with adjusted risk ratios of 1.59 (1.21–2.08) for uptake, 2.24 (1.47–3.42) for diagnosis and 5.78 (1.60–21.6) for referral. The intervention was highly cost-effective.

Electronic algorithms applied to practice systems could enhance testing and diagnosis of hepatitis C in primary care, contributing to global elimination goals.Roberts K, Macleod J, Metcalfe C, et al. Cost-effectiveness of an intervention to increase uptake of hepatitis C viagra testing and treatment (HepCATT). Cluster randomised controlled trial in primary care. BMJ 2020;368:m322. Doi:10.1136/bmj.m322Low completion rates for antiretroviral postexposure prophylaxis (PEP) after sexual assaultA 4-week course of triple-agent postexposure prophylaxis (PEP) is recommended following a high-risk sexual assault.3 4 A retrospective study in Barcelona identified 1695 victims attending an emergency room (ER) between 2006 and 2015.

Overall, 883 (52%) started prophylaxis in ER, which was mostly (43%) lopinavir/ritonavir based. Follow-up appointments were arranged for those living in Catalonia (631, 71.5%), and of these, only 183 (29%) completed treatment. Loss to follow-up was more prevalent in those residing outside Barcelona. PEP non-completion was associated with a low perceived risk, previous assaults, a known aggressor and a positive cocaine test. Side effects were common, occurring in up to 65% of those taking lopinavir/ritonavir and accounting for 15% of all discontinuations.

More tolerable PEP regimens, accessible follow-up and provision of 1-month supply may improve completion rates.Inciarte A, Leal L, Masfarre L, et al. Postexposure prophylaxis for HIV in sexual assault victims. HIV Med 2020;21:43–52. Doi:10.1111/hiv.12797.Effective antiretroviral therapy reduces anal high-risk HPV and cancer riskAmong people with HIV, effective antiretroviral therapy (ART) is expected to improve control of anal with high-risk human papillomaviagra (HR-HPV) and reduce the progression of HPV-associated anal lesions. The magnitude of the effect is not well established.

By meta-analysis, people on established ART (vs ART-naive) had a 35% lower prevalence of HR-HPV , and those with undetectable viral load (vs detectable viral load) had a 27% and 16% reduced risk of low and high-grade anal lesions, respectively. Sustained virological suppression on ART reduced by 44% the risk of anal cancer. The role of effective ART in reducing anal HR-HPV and cancer risks is especially salient given current limitations in anal cancer screening, high rates of anal lesion recurrence and access to vaccination.Kelly H, Chikandiwa A, Alemany Vilches L, et al. Association of antiretroviral therapy with anal high-risk human papillomaviagra, anal intraepithelial neoplasia and anal cancer in people living with HIV. A systematic review and meta-analysis.

Lancet HIV. 2020;7:e262–78. Doi:10.1016/S2352-3018(19)30434-5.The impact of sex work laws and stigma on HIV prevention among female sex workersSex work laws and stigma have been established as structural risk factors for HIV acquisition among female sex workers (FSWs). However, individual-level data assessing these relationships are limited. A study examined individual-level data collected in 2011–2018 from 7259 FSWs across 10 sub-Saharan African countries.

An association emerged between HIV prevalence and increasingly punitive and non-protective laws. HIV prevalence among FSWs was 11.6%, 19.6% and 39.4% in contexts where sex work was partly legalised, not recognised or criminalised, respectively. Stigma measures such as fear of seeking health services, mistreatment in healthcare settings, lack of police protection, blackmail and violence were associated with higher HIV prevalence and more punitive settings. Sex work laws that protect sex workers and reduce structural risks are needed.Lyons CE, Schwartz SR, Murray SM, et al. The role of sex work laws and stigmas in increasing HIV risks among sex workers.

Nat Commun 2020;11:773. Doi:10.1038/s41467-020-14593-6.BackgroundCumbria Sexual Health Services (CSHS) in collaboration with Cumbria Public Health and local authorities have established a erectile dysfunction treatment contact tracing pathway for Cumbria. The local system was live 10 days prior to the national system on 18 May 2020. It was designed to interface and dovetail with the government’s track and trace programme.Our involvement in this initiative was due to a chance meeting between Professor Matt Phillips, Consultant in Sexual Health and HIV, and the Director of Public Health Cumbria, Colin Cox. Colin knew that Cumbria needed to act fast to prevent the transmission of erectile dysfunction treatment and Matt knew that sexual health had the skills to help.ProcessDespite over 90% of the staff from CSHS being redeployed in March 2020, CSHS maintained urgent sexual healthcare for the county and a phone line for advice and guidance.

As staff began to return to the service in May 2020 we had capacity to spare seven staff members, whose hours were the equivalent of four full-time staff. We had one system administrator, three healthcare assistants, one nurse, Health Advisor Helen Musker and myself.CSHS were paramount to the speed with which the local system began. Following approval from the Trust’s chief executive officer we had adapted our electronic patient records (EPR) system, developed a standard operating procedure and trained staff, using a stepwise competency model, within just 1 day.In collaboration with the local laboratories we developed methods for the input of positive erectile dysfunction treatment results into our EPR derivative. We ensured that labs would be able to cope with the increase in testing and that testing hubs had additional capacity. Testing sites and occupational health were asked to inform patients that if they tested positive they would be contacted by our teams.This initiative involved a multiagency system including local public health (PH) teams, local authority, North Cumbria and Morecambe Bay CCGs, Public Health England (PHE) and the military.

If CSHS recognise more than one positive result in the same area/organisation, they flag this with PH at the daily incident management meeting and environmental health officers (EHOs) provide advice and guidance for the organisation. We have had an active role in the contact tracing for clusters in local general practices, providing essential information to PH to enable them to initiate outbreak control and provide accurate advice to the practices. We are an integral part in recognising cases in large organisations and ensuring prompt action is taken to stem the spread of the disease. The team have provided out-of-hours work to ensure timely and efficient action is taken for all contacts.The local contact tracing pilot has evolved and a database was established by local authorities. Our data fed directly into this from the end of May 2020.

This enables the multiagency team to record data in one place, improving recognition of patterns of transmission.DiscussionCumbria is covered by three National Health Service Trusts, which meant accessing data outside of our Trust was challenging and took more time to establish. There are two CCGs for Cumbria, which meant discussions regarding testing were needed with both North and South CCGs and variations in provision had to be accounted for. There are six boroughs in Cumbria with different teams of EHOs working in each. With so many people involved, not only is there need for large-scale frequent communication across a multisystem team, there is also inevitable duplication of work.Lockdown is easing and sexual health clinics are increasing capacity in a new world of virtual appointments and reduced face-to-face consultations. Staff within the contact tracing team are now balancing their commitments across both teams to maintain their skills and keep abreast of the rapid developments within our service due to erectile dysfunction treatment.

We are currently applying for funding from PH in order to second staff and backfill posts in sexual health.ConclusionCSHS have been able to lend our skills effectively to the local contact tracing efforts. We have expedited the contact tracing in Cumbria and provided crucial information to help contain outbreaks. It has had a positive effect on staff morale within the service and we have gained national recognition for our work. We have developed excellent relationships with our local PH team, PHE, Cumbria Council, EHOs and both CCGs.Cumbria has the infrastructure to meet the demands of a second wave of erectile dysfunction treatment. The beauty of this model is that if we are faced with a second lockdown, sexual health staff will inevitably be available to help with the increased demand for contact tracing.

Our ambition is that this model will be replicated nationally..

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Each patient's treatment was how much viagra should i take for fun customized based on key "neoantigens" -- abnormal proteins -- that were present on their tumor cells.Even though those proteins are foreign, the immune system is not able, on its own, to generate a major response against them."The problem is, the tumor itself doesn't present enough of a danger signal," said Dr. Patrick Ott, one of the researchers on the new how much viagra should i take for fun study.Beyond that, tumors have various ways of eluding the body's defenses, explained Ott, of the Dana-Farber Cancer Institute in Boston.The idea behind NeoVax is to present the immune system with the tumor neoantigens so it can generate a focused T cell response against them. T cells are immune system sentries that can find and destroy cancer cells.In earlier work, Ott and his colleagues found the treatment safely activated a tumor-directed T cell response in six melanoma patients.

The new study looked at the how much viagra should i take for fun longer-term response in those patients, plus an additional two who've received the treatment since.After a typical follow-up of four years, all eight patients were still alive and showing a sustained T cell response to their cancer.What was "striking," Ott said, was that the immune response not only persisted, but had broadened. The patients' T cells remembered the proteins the treatment had presented, and had "diversified" to recognize other melanoma proteins that had not been included in the treatment.The big question, though, is whether it makes a difference in patients' outcomes.Five of the eight patients did see their melanoma recur. In two cases, Ott said, the recurrences happened early, and the patients were given drugs called checkpoint inhibitors.Checkpoint inhibitors, like the cancer treatment, fall under the umbrella of "immunotherapy" -- treatments that enlist the immune system to help destroy tumor cells.The drugs work by removing the "brakes" from T cells' ability to respond to tumor cells how much viagra should i take for fun.

And they are already a standard part of care how much viagra should i take for fun for melanoma patients like those in this study.When the two study patients with early recurrences started on checkpoint inhibitors, they quickly responded, showing a complete resolution of their tumors. According to Ott, that suggests the treatment might have worked in concert with the checkpoint inhibitors, generating a T cell response that the medications then freed up.The only way to know whether the treatment improves patients' outlook, however, is through a clinical trial, said Dr. Ahmad Tarhini, a melanoma specialist and researcher who was not involved in the study.That, he explained, would mean randomly assigning melanoma patients to either have the treatment added to standard treatment with checkpoint inhibitors, or have standard treatment alone.Based on these patients, the treatment by itself might not be enough to prevent melanoma recurrences, said Tarhini, a senior member of the departments of cutaneous oncology and immunology at Moffitt Cancer Center in Tampa, Fla.That said, Tarhini called the how much viagra should i take for fun current findings an important step forward in creating customized cancer treatments."As a proof-of-principle, this is successful," Tarhini said.

"The treatment can induce a durable immune system response that is well-tolerated."In theory, Ott said, personalized treatments how much viagra should i take for fun could be used for a range of cancers. NeoVax is being studied as an additional therapy for other cancers, including later-stage ovarian and kidney cancers.If the approach eventually proves to keep cancer recurrences at bay, Ott noted, there will be real-world issues -- namely, the time and money it takes to create personalized treatments. SLIDESHOW Sun-Damaged how much viagra should i take for fun Skin.

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Ott, MD, PhD, clinical director, Melanoma Disease Center, Dana-Farber Cancer Institute, associate professor, medicine, Harvard Medical School, Boston. Ahmad Tarhini, MD, senior member, departments of cutaneous oncology and immunology, and director, cutaneous clinical and translational research, Moffitt Cancer Center, Tampa, how much viagra should i take for fun Fla.. Nature Medicine, Jan.

21, 2021, onlineCopyright © 2020 HealthDay. All rights reserved. From Skin Protection Resources Featured Centers Health Solutions From Our Sponsors.

Latest Cancer News By Amy Norton 100mg viagra for sale HealthDay ReporterMONDAY, Jan. 25, 2021 (HealthDay News)Giving melanoma patients a "personalized" treatment can prompt an anti-tumor immune response that lasts for years, an early study finds.The study involved just eight patients with advanced melanoma, the 100mg viagra for sale deadliest form of skin cancer.But it builds on earlier work showing it is possible to spur the immune system to respond to an individual's unique tumor.All eight patients underwent standard surgery for their melanoma, but were considered high risk for a recurrence. So researchers gave them an experimental treatment called NeoVax.Unlike traditional treatments, it is not a one-size-fits-all jab. Each patient's treatment was customized based on key "neoantigens" -- abnormal proteins -- that were present on their tumor cells.Even though those proteins are foreign, the immune system is not able, on its own, to generate a major response against them."The problem is, the tumor 100mg viagra for sale itself doesn't present enough of a danger signal," said Dr. Patrick Ott, one of the researchers on the new study.Beyond that, tumors have 100mg viagra for sale various ways of eluding the body's defenses, explained Ott, of the Dana-Farber Cancer Institute in Boston.The idea behind NeoVax is to present the immune system with the tumor neoantigens so it can generate a focused T cell response against them.

T cells are immune system sentries that can find and destroy cancer cells.In earlier work, Ott and his colleagues found the treatment safely activated a tumor-directed T cell response in six melanoma patients. The new study looked at the longer-term response in those patients, plus an additional two who've received the treatment since.After a typical follow-up of four years, all eight patients 100mg viagra for sale were still alive and showing a sustained T cell response to their cancer.What was "striking," Ott said, was that the immune response not only persisted, but had broadened. The patients' T cells remembered the proteins the treatment had presented, and had "diversified" to recognize other melanoma proteins that had not been included in the treatment.The big question, though, is whether it makes a difference in patients' outcomes.Five of the eight patients did see their melanoma recur. In two cases, Ott said, the recurrences happened early, and the patients were given drugs called checkpoint inhibitors.Checkpoint inhibitors, like the cancer treatment, fall under the umbrella of "immunotherapy" -- treatments that 100mg viagra for sale enlist the immune system to help destroy tumor cells.The drugs work by removing the "brakes" from T cells' ability to respond to tumor cells. And they are already a standard part of care for melanoma patients like those in this study.When the two study patients with 100mg viagra for sale early recurrences started on checkpoint inhibitors, they quickly responded, showing a complete resolution of their tumors.

According to Ott, that suggests the treatment might have worked in concert with the checkpoint inhibitors, generating a T cell response that the medications then freed up.The only way to know whether the treatment improves patients' outlook, however, is through a clinical trial, said Dr. Ahmad Tarhini, a melanoma specialist and researcher who was not involved in the study.That, he explained, would mean randomly assigning melanoma patients to either have the treatment added to standard treatment with checkpoint inhibitors, or have standard treatment alone.Based on these patients, the treatment by itself might not be enough to prevent melanoma recurrences, 100mg viagra for sale said Tarhini, a senior member of the departments of cutaneous oncology and immunology at Moffitt Cancer Center in Tampa, Fla.That said, Tarhini called the current findings an important step forward in creating customized cancer treatments."As a proof-of-principle, this is successful," Tarhini said. "The treatment 100mg viagra for sale can induce a durable immune system response that is well-tolerated."In theory, Ott said, personalized treatments could be used for a range of cancers. NeoVax is being studied as an additional therapy for other cancers, including later-stage ovarian and kidney cancers.If the approach eventually proves to keep cancer recurrences at bay, Ott noted, there will be real-world issues -- namely, the time and money it takes to create personalized treatments. SLIDESHOW Sun-Damaged Skin 100mg viagra for sale.

Pictures of Sun Spots, Wrinkles, Sunburns See Slideshow Dana-Farber, the primary site for the NeoVax research, says it holds "a proprietary and financial interest in the personalized neoantigen treatment."The study was published 100mg viagra for sale Jan. 21 in Nature Medicine.More informationThe American Cancer Society has more on cancer immunotherapy.SOURCES. Patrick A 100mg viagra for sale. Ott, MD, PhD, clinical director, Melanoma Disease Center, Dana-Farber Cancer Institute, associate professor, medicine, Harvard Medical School, Boston. Ahmad Tarhini, MD, senior member, 100mg viagra for sale departments of cutaneous oncology and immunology, and director, cutaneous clinical and translational research, Moffitt Cancer Center, Tampa, Fla..

Nature Medicine, 100mg viagra for sale Jan. 21, 2021, onlineCopyright © 2020 HealthDay. All rights reserved. From Skin Protection Resources Featured Centers Health Solutions From Our Sponsors.

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SALT LAKE useful site CITY, female viagra sildenafil Jan. 11, 2021 /PRNewswire/ -- Health Catalyst, Inc female viagra sildenafil. ("Health Catalyst," Nasdaq. HCAT), a female viagra sildenafil leading provider of data and analytics technology and services to healthcare organizations, today announced that Stephen Grossbart, Ph.D., Senior Vice President of Professional Services, has been re-appointed to National Quality Forum's (NQF) Primary Care and Chronic Illness Standing Committee.

Grossbart has served on the Committee since 2017 and its precursor, Pulmonary and Critical Care Standing Committee, since 2012. Commenting on the female viagra sildenafil appointment, Grossbart said. "As our nation continues to face the unprecedented challenges of the erectile dysfunction, the implementation and effectiveness of healthcare quality measures and improvement strategies is of special importance. It's an honor to be named to NQF's Primary Care and Chronic Illness Standing Committee and I look forward to partnering with my fellow committee members to develop and advise on measures that will best support healthcare stakeholders and drive measurable improvements."Members of the Primary Care and Chronic Illness Standing Committee are responsible for overseeing measures related to endocrine, infectious disease, female viagra sildenafil musculoskeletal and pulmonary care.

Measures endorsed by NQF are a benchmark for healthcare measurement in the United States and are critically important to healthcare outcomes improvement and efforts to treat and prevent chronic illness and infectious disease. About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations committed female viagra sildenafil to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial, and operational improvements. Health Catalyst female viagra sildenafil envisions a future in which all healthcare decisions are data informed.Media Contact:Amanda Hundtamanda.hundt@healthcatalyst.com575-491-0974 View original content to download multimedia:http://www.prnewswire.com/news-releases/health-catalyst-leader-appointed-to-primary-care-and-chronic-illness-standing-committee-301204733.htmlSOURCE Health CatalystSALT LAKE CITY, Dec.

22, 2020 (GLOBE NEWSWIRE) -- Health Catalyst, Inc. ("Health Catalyst", female viagra sildenafil Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today announced that Dan Burton, CEO, Bryan Hunt, CFO and Adam Brown, SVP of Investor Relations and FP&A, will participate in the 39th Annual J.P. Morgan Healthcare Conference to female viagra sildenafil be held virtually January 11-14, 2021.

This will include a presentation by Mr. Burton and female viagra sildenafil Mr. Hunt on Monday, January 11, 2021 at 5:20 p.m. EST.

An audio replay of the presentation will be available at https://ir.healthcatalyst.com/investor-relations. About Health Catalyst Health Catalyst is a leading provider of data and analytics technology and services to healthcare organizations committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial, and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.

Health Catalyst Investor Relations Contact. Adam BrownSenior Vice President, Investor Relations and FP&A+1 (855)-309-6800ir@healthcatalyst.com Health Catalyst Media Contact. Amanda HundtVice President, Corporate Communications+1 (575) 491-0974amanda.hundt@healthcatalyst.comAdvertisementContinue reading the main storySupported byContinue reading the main storyPhys EdThe Best Time of Day to ExerciseMen at risk for diabetes had greater blood sugar control and lost more belly fat when they exercised in the afternoon than in the morning.Credit...Getty ImagesJan. 27, 2021Is it better for our bodies to work out at certain times of day?.

A useful new study of exercise timing and metabolic health suggests that, at least for some people, the answer is a qualified yes. The study, which looked at men at high risk for Type 2 diabetes, found that those who completed afternoon workouts upped their metabolic health far more than those who performed the same exercise earlier in the day. The results add to growing evidence that when we exercise may alter how we benefit from that exercise.Scientists have known for some time that the chronology of our days influences the quality of our health. Studies in both animals and people indicate that every tissue in our bodies contains a kind of molecular clock that chimes, in part, in response to biological messages related to our daily exposure to light, food and sleep.These cellular clocks then help to calibrate when our cells divide, fuel up, express genes and otherwise go about their normal biological work.

Tuned by our lifestyles, these clocks create multiple circadian rhythms inside of us that prompt our bodies’ temperatures, hormone levels, blood sugar, blood pressure, muscular strength and other biological systems to dip and crest throughout the day.Circadian science also shows that disrupting normal, 24-hour circadian patterns can impair our health. People working overnight shifts, for instance, whose sleep habits are upended, tend to be at high risk for metabolic problems such as obesity and Type 2 diabetes. The same is true for people who eat late at night, outside usual dinner hours. More encouraging research suggests, though, that manipulating the timing of sleep and meals can improve metabolic health.But much of this research focused on when we eat or go to bed.

Whether, and how, exercise timing might influence metabolic health has been less clear, and the results of past experiments have not always agreed. Some suggest that morning workouts, for instance, amplify fat burning and weight loss.But those experiments often manipulated the timing of breakfast and other meals, as well as exercise, making it difficult to tease out the particular, circadian effects of workouts. They also typically involved healthy volunteers, without metabolic problems.A much-discussed 2019 study, on the other hand, found that men with Type 2 diabetes who completed a few minutes of high-intensity interval sessions in the afternoon substantially improved their blood-sugar control after two weeks. If they did the same, intense workouts in the morning, however, their blood-sugar levels actually spiked in an unhealthy fashion.Patrick Schrauwen, a professor of nutrition and movement sciences at Maastricht University Medical Center in the Netherlands, read that 2019 study with interest.

He and his colleagues had been studying moderate exercise in people with Type 2 diabetes, but in their research, they had not considered the possible role of timing. Now, seeing the varying impacts of the intense workouts, he wondered if the timing of moderate workouts might likewise affect how the workouts changed people’s metabolisms.Fortuitously, he and his colleagues had a ready-made source of data, in their own prior experiment. Several years earlier, they had asked adult men at high risk for Type 2 diabetes to ride stationary bicycles at the lab three times a week for 12 weeks, while the researchers tracked their metabolic health. The scientists also, incidentally, had noted when the riders showed up for their workouts.Now, Dr.

Schrauwen and his colleagues pulled data for the 12 men who consistently had worked out between 8 and 10 a.m. And compared them with another 20 who always exercised between 3 and 6 p.m. They found that the benefits of afternoon workouts decisively trumped those of morning exercise.After 12 weeks, the men who had pedaled in the afternoon displayed significantly better average insulin sensitivity than the morning exercisers, resulting in a greater ability to control blood sugar. They also had dropped somewhat more fat from around their middles than the morning riders, even though everyone’s exercise routines had been identical.“I believe that doing exercise is better than not doing exercise, irrespective of timing,” Dr.

Schrauwen says. €œHowever, this study does suggest that afternoon exercise may be more beneficial” for people with disrupted metabolisms than the same exercise done earlier.The study, in Physiological Reports, involved only men, though. Women’s metabolisms might respond differently.The researchers also did not delve into why the later workouts might affect metabolism differently than earlier ones. But Dr.

Schrauwen says he believes moderate afternoon exercise may have an impact on the foods we consume later in the evening and “help to faster metabolize people’s last meals” before they go to sleep. This effect could leave our bodies in a fasted state overnight, which may better synchronize body clocks and metabolisms and fine-tune health.He and his colleagues hope to explore the underlying molecular effects in future studies, as well as whether the timing of lunch and dinner alters those results. The team also hopes to look into whether evening workouts might amplify the benefits of afternoon exertion, or perhaps undercut them, by worsening sleep.Ultimately, Dr. Schrauwen says, the particular, most effective exercise regimen for each of us will align “with our daily routines” and exercise inclinations.

Because exercise is good for us at any time of day — but only if we opt to keep doing it.AdvertisementContinue reading the main story.

SALT LAKE 100mg viagra for sale CITY, http://www.waitingroomn16.com/cheap-zithromax-online/ Jan. 11, 2021 /PRNewswire/ -- Health Catalyst, Inc 100mg viagra for sale. ("Health Catalyst," Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today announced that Stephen Grossbart, Ph.D., Senior Vice President of Professional 100mg viagra for sale Services, has been re-appointed to National Quality Forum's (NQF) Primary Care and Chronic Illness Standing Committee. Grossbart has served on the Committee since 2017 and its precursor, Pulmonary and Critical Care Standing Committee, since 2012.

Commenting on the appointment, Grossbart said 100mg viagra for sale. "As our nation continues to face the unprecedented challenges of the erectile dysfunction, the implementation and effectiveness of healthcare quality measures and improvement strategies is of special importance. It's an honor to be named to NQF's Primary Care and Chronic Illness Standing Committee and I look forward to partnering with my fellow committee members to develop and advise on 100mg viagra for sale measures that will best support healthcare stakeholders and drive measurable improvements."Members of the Primary Care and Chronic Illness Standing Committee are responsible for overseeing measures related to endocrine, infectious disease, musculoskeletal and pulmonary care. Measures endorsed by NQF are a benchmark for healthcare measurement in the United States and are critically important to healthcare outcomes improvement and efforts to treat and prevent chronic illness and infectious disease. About Health 100mg viagra for sale CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations committed to being the catalyst for massive, measurable, data-informed healthcare improvement.

Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial, and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.Media 100mg viagra for sale Contact:Amanda Hundtamanda.hundt@healthcatalyst.com575-491-0974 View original content to download multimedia:http://www.prnewswire.com/news-releases/health-catalyst-leader-appointed-to-primary-care-and-chronic-illness-standing-committee-301204733.htmlSOURCE Health CatalystSALT LAKE CITY, Dec. 22, 2020 (GLOBE NEWSWIRE) -- Health Catalyst, Inc. ("Health Catalyst", 100mg viagra for sale Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today announced that Dan Burton, CEO, Bryan Hunt, CFO and Adam Brown, SVP of Investor Relations and FP&A, will participate in the 39th Annual J.P.

Morgan Healthcare Conference to be held virtually January 100mg viagra for sale 11-14, 2021. This will include a presentation by Mr. Burton and Mr 100mg viagra for sale. Hunt on Monday, January 11, 2021 at 5:20 p.m. EST.

An audio replay of the presentation will be available at https://ir.healthcatalyst.com/investor-relations. About Health Catalyst Health Catalyst is a leading provider of data and analytics technology and services to healthcare organizations committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial, and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed. Health Catalyst Investor Relations Contact.

Adam BrownSenior Vice President, Investor Relations and FP&A+1 (855)-309-6800ir@healthcatalyst.com Health Catalyst Media Contact. Amanda HundtVice President, Corporate Communications+1 (575) 491-0974amanda.hundt@healthcatalyst.comAdvertisementContinue reading the main storySupported byContinue reading the main storyPhys EdThe Best Time of Day to ExerciseMen at risk for diabetes had greater blood sugar control and lost more belly fat when they exercised in the afternoon than in the morning.Credit...Getty ImagesJan. 27, 2021Is it better for our bodies to work out at certain times of day?. A useful new study of exercise timing and metabolic health suggests that, at least for some people, the answer is a qualified yes. The study, which looked at men at high risk for Type 2 diabetes, found that those who completed afternoon workouts upped their metabolic health far more than those who performed the same exercise earlier in the day.

The results add to growing evidence that when we exercise may alter how we benefit from that exercise.Scientists have known for some time that the chronology of our days influences the quality of our health. Studies in both animals and people indicate that every tissue in our bodies contains a kind of molecular clock that chimes, in part, in response to biological messages related to our daily exposure to light, food and sleep.These cellular clocks then help to calibrate when our cells divide, fuel up, express genes and otherwise go about their normal biological work. Tuned by our lifestyles, these clocks create multiple circadian rhythms inside of us that prompt our bodies’ temperatures, hormone levels, blood sugar, blood pressure, muscular strength and other biological systems to dip and crest throughout the day.Circadian science also shows that disrupting normal, 24-hour circadian patterns can impair our health. People working overnight shifts, for instance, whose sleep habits are upended, tend to be at high risk for metabolic problems such as obesity and Type 2 diabetes. The same is true for people who eat late at night, outside usual dinner hours.

More encouraging research suggests, though, that manipulating the timing of sleep and meals can improve metabolic health.But much of this research focused on when we eat or go to bed. Whether, and how, exercise timing might influence metabolic health has been less clear, and the results of past experiments have not always agreed. Some suggest that morning workouts, for instance, amplify fat burning and weight loss.But those experiments often manipulated the timing of breakfast and other meals, as well as exercise, making it difficult to tease out the particular, circadian effects of workouts. They also typically involved healthy volunteers, without metabolic problems.A much-discussed 2019 study, on the other hand, found that men with Type 2 diabetes who completed a few minutes of high-intensity interval sessions in the afternoon substantially improved their blood-sugar control after two weeks. If they did the same, intense workouts in the morning, however, their blood-sugar levels actually spiked in an unhealthy fashion.Patrick Schrauwen, a professor of nutrition and movement sciences at Maastricht University Medical Center in the Netherlands, read that 2019 study with interest.

He and his colleagues had been studying moderate exercise in people with Type 2 diabetes, but in their research, they had not considered the possible role of timing. Now, seeing the varying impacts of the intense workouts, he wondered if the timing of moderate workouts might likewise affect how the workouts changed people’s metabolisms.Fortuitously, he and his colleagues had a ready-made source of data, in their own prior experiment. Several years earlier, they had asked adult men at high risk for Type 2 diabetes to ride stationary bicycles at the lab three times a week for 12 weeks, while the researchers tracked their metabolic health. The scientists also, incidentally, had noted when the riders showed up for their workouts.Now, Dr. Schrauwen and his colleagues pulled data for the 12 men who consistently had worked out between 8 and 10 a.m.

And compared them with another 20 who always exercised between 3 and 6 p.m. They found that the benefits of afternoon workouts decisively trumped those of morning exercise.After 12 weeks, the men who had pedaled in the afternoon displayed significantly better average insulin sensitivity than the morning exercisers, resulting in a greater ability to control blood sugar. They also had dropped somewhat more fat from around their middles than the morning riders, even though everyone’s exercise routines had been identical.“I believe that doing exercise is better than not doing exercise, irrespective of timing,” Dr. Schrauwen says. €œHowever, this study does suggest that afternoon exercise may be more beneficial” for people with disrupted metabolisms than the same exercise done earlier.The study, in Physiological Reports, involved only men, though.

Women’s metabolisms might respond differently.The researchers also did not delve into why the later workouts might affect metabolism differently than earlier ones. But Dr. Schrauwen says he believes moderate afternoon exercise may have an impact on the foods we consume later in the evening and “help to faster metabolize people’s last meals” before they go to sleep. This effect could leave our bodies in a fasted state overnight, which may better synchronize body clocks and metabolisms and fine-tune health.He and his colleagues hope to explore the underlying molecular effects in future studies, as well as whether the timing of lunch and dinner alters those results. The team also hopes to look into whether evening workouts might amplify the benefits of afternoon exertion, or perhaps undercut them, by worsening sleep.Ultimately, Dr.

Schrauwen says, the particular, most effective exercise regimen for each of us will align “with our daily routines” and exercise inclinations. Because exercise is good for us at any time of day — but only if we opt to keep doing it.AdvertisementContinue reading the main story.

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In this issue of the Journal of Medical Ethics arguments are cogently made that sustainability and solidarity should be considered as core medical ethical principles, and that more explicit attention should be given to the complex context in which a decision viagra street price is made.Munthe et al propose that sustainability should become an established principle for justifying healthcare resource allocation, and should can i get viagra over the counter at walmart be an explicit factor in procuring drugs and other resources.1 They argue that the current operational norms which guide decision making (need, prognosis, equal treatment and cost-effectiveness) can lead to what they call ‘negative dynamics’. The gradual depletion of resource available for healthcare.They illustrate this first by examining some well recognised examples of ‘positive dynamics’ which are considered in health policy. Immunisation programmes are funded because lead to reduction or absence of disease in the population, thus freeing up resource for other viagra street price uses. Public health measures are offset by future cost reductions or income increases for healthcare via reduction of sick leave.‘Negative dynamics’ however, are not routinely considered in operational decisions and they persuasively argue that they should be. Resource depletion (not only fiscal viagra street price resource, but environmental and human resource) has a negative effect on future cycles of healthcare.

As an illustrative example, they discuss the emission of resistance-driving residue in the production of antibiotics. The accepted principles, particularly of viagra street price cost effectiveness, drive producers to make antibiotics cheaply, without consideration of gradual contribution to antibiotic resistance. If a principle of sustainability was included when considering procurement, subsidy and prioritisation, this would provide an incentive to change production practices. This argument viagra street price can be extended to many aspects of the healthcare. System including how we recruit, train and treat our staff.

How we invest in infrastructure and how we viagra street price plan for viagras. Munthe et al go on to provide a robust definition of their sustainability principle, and to address possible objections. It is an excellent example of reasoned ethical argument which has the potential to change clinical practice.With the roll out of vaccinations for erectile dysfunction treatment across the globe, Julian Savulescu proposes viagra street price an algorithm for when mandatory vaccination might be ethically justified.2 Drawing and expanding upon the 2007 Nuffield Council of Bioethics report he suggests that four criteria are required. 1. There is a viagra street price grave threat to public health 2.

The treatment is safe and effective 3. Mandatory vaccination has a superior cost/benefit profile compared with other viagra street price alternatives 4. The level of coercion is proportionate. Discussing the viagra street price value judgement associated with each criterion, he concludes that, at least initially (where uncertainty around safety is greater), mandatory vaccination for erectile dysfunction treatment would be ethically problematic.He goes on to explore alternative approaches, including non-financial (eg, immunisation passports) and financial incentives. He argues that individuals could essentially be paid for the risk they are undertaking (by being early adopters of a treatment) for societal benefit, but to do this government would need to be ‘transparent, explicit and comprehensive in disclosure of data’, a standard which unfortunately has not always (or even often?.

) been kept viagra street price. The danger that payment might signal a lack of confidence in safety is real. Clearly payment should only be offered for a viagra street price treatment which was considered safe enough to be used in any circumstances. Payment for a treatment which was not considered safe without payment would not be morally acceptable. Payment may also erode the viagra street price sense of solidarity that people feel when contributing to societal well-being.

To ensure that this was maintained he suggests the option of ‘donating back’ the fee to the NHS could be made available. People could be rewarded for taking the treatment with an increasing sense of civic duty as they not only protect themselves and the vulnerable, but contribute to the (fiscal) sustainability of the health service which treats them.While Savulescu acknowledges the worth of solidarity, Avery Kolers proposes that solidarity plays viagra street price not just an auxillary part in the interests of acknowledged bioethical values (justice, beneficence etc) but has a freestanding role, which should be independently assessed.3 He acknowledges that solidarity per se is not valuable. There is solidarity, he notes, among a firing squad and within a terrorist cell. He develops Prainsack and Buyx metaphor of solidarity as the putty of justice4 and suggests five individually necessary and sufficient conditions of morally viagra street price valuable solidarity. It must be (1) norm grounded (2) acknowledged (3) political (4) action and (5) on others’ behalf.

He suggests that solidarity viagra street price (with X) is morally required ‘when it constitutes equitable treatment of X such as to countermand or resist inequitable treatment of X’. He notes that moral dilemmas may arise where solidarity with X may lead to inequitable treatment of Y and emphasises that solidarity with the most vulnerable in society will help address inequities in healthcare and in healthcare institutions.The complexities and competing moral demands of healthcare institutions, and primary care in particular, are explored by Spicer et al, who question the use of normative moral theories to determine the ‘best’ actions.5 They argue that the context in which ethical decisions are made is not sufficiently acknowledged. If complex contextual factors are not considered, then predictions about outcomes will be flawed, as will the resulting viagra street price ethical analyses.Examples of contextual factors which might influence decision-making include power relations within the staff and external regulators (including achieving externally determined quality markers and ‘standard’ practice) and the need to maintain both group and individual professional identities.It is often helpful to peel back the layers of complexity in order to reveal a specific ethical question. Before coming to a conclusion, however, we must remember to reapply the layers and reconsider the question in the context of its complex environment. Integrating this proposal with others in the journal, this might include considerations of sustainability and solidarity.IntroductionWhile the role and importance of solidarity has been the focus of long-running and extensive debate surrounding public health ethics viagra street price and practice,1 the erectile dysfunction treatment viagra has cast this debate into even starker relief.2 In doing so, it has emphasised the particular importance of solidarity for the delivery of effective public health programmes by highlighting the potentially disastrous consequences of its absence.

In this paper I examine these consequence with reference to the response of the current British government to erectile dysfunction treatment which failed to deliver an effective public health response to the crisis. I argue that this response represents mismanagement of a public health crisis, and a rejection of important democratic norms and values.Defining solidaritySolidarity has a wide range of definitions in academic discourse, with its precise features being the subject of heated debate.3 4 Historically, solidarity has been seen as emerging most readily, and most often between persons sharing relatively stable, deeply ingrained qualities, such as shared membership of a state or religious group,5 or commitment to shared political ideals and objectives.6 7 More recently, it has been suggested that more transient, or less deeply ingrained features of persons may serve as the basis for acts of solidarity, and at least short-term solidarity relationships.4 On a larger scale, it has also been suggested that recognition of shared vulnerability in the face of global threats to health, such as climate change and antimicrobial resistance, may serve as a catalyst for solidarity between nations and peoples.8 As I explain below, this perspective is particularly relevant to the current viagra context.2In this paper I rely mainly on the definition of solidarity offered by Prainsack and Buyx, who define solidarity as ‘enacted commitments viagra street price to accept costs to assist others with whom a person or persons recognise similarity in a relevant respect’.4 Therefore, solidarity describes what it is that we do when we assist, benefit or support other people because we recognise some form of relevant similarity or connection with/to them. Thus solidarity is active, in that it is something we do, not merely a feeling or attitude. It is also egalitarian, with motivation for action being grounded in recognition of what is shared between parties, not in what distinguishes them.3 Finally, acting in solidarity also involves incurring of costs of some kind, though these may be extremely minimal, or be viagra street price counterbalanced by the benefits of a given solidarity action.Prainsack and Buyx argue that there are three main ‘tiers’ of solidaristic action. Interpersonal, group and institutional solidarity.4 The first of these tiers describes what happens between individual persons.

For example, Prainsack and Buyx suggest that giving up one’s seat on a crowded bus for a pregnant fellow passenger is an act of solidarity when based on recognition of shared experience of discomfort while standing during pregnancy.4 The second tier ‘comprises manifestations of a shared commitment to carry costs to assist others with whom people consider themselves viagra street price bound together through at least one similarity in a relevant respect’. These group solidarities occur when many individuals share a similar specific context, and engage in actions to benefit others with whom the context is shared. Such solidarity is informal, though it viagra street price may also be heavily normalised within a given community, such that it forms an expectation of behaviour.Tier 3 solidarity comprises formalised, or legally mandated expectations of behaviour. Here, solidarity is fully institutionalised, ‘in the form of legally enforceable norms’,4 such as progressive tax systems and welfare state arrangements. For example, the British National Health Service (NHS) exemplifies institutionalised solidarity, because it is funded through taxation and provides healthcare viagra street price to citizens and legal residents of the UK, regardless of their ability to pay.

According to Prainsack and Buyx, these three tiers of solidarity are closely connected, with tier 3 solidarity typically emerging from solidarity at tiers 1 and 2. Correlatively, Sangiovanni discusses viagra street price the participation in collaborative institutions as solidaristic practice when he argues that solidarity is grounded in ‘our joint action as authors of political and social institutions’.7 Thus, for Sangiovanni solidarity is something which emerges from shared participation in the construction and enactment of http://mccarthyschoolofirishdance.com/ civic society. Solidarity can therefore be interpreted in a range of ways—as the act of carrying costs for relevantly similar others, ‘standing up for’, ‘standing up with’ and ‘standing up as’’ those persons with whom solidarity is identified,3 or the act of working together for a shared goal.7 Regardless of the precise definition adopted, at least basic solidarity, as active engagements in interpersonal and/or institutional egalitarian relationality, by all or most members of a group is fundamentally necessary for the existence and functioning of any community—as I explain below, it is particularly important in democracies.Solidarity and public healthIn normal circumstances, private individuals can engage in interpersonal and group solidarity in the context of public health provision, by avoiding social interaction when sick and helping others to do the same, by purchasing groceries for an ill neighbour, for example. Individuals can engage in viagra street price tier 3 solidarity by participating in institutions which promote and protect public and individual health. For example, participation in fair taxation schemes can help fund health and welfare programmes, such as the British NHS, ensuring the accessibility of these services to all members of a given community, thereby contributing to public health and individual well-being.Correlatively, while elected and appointed governmental officials, such as cabinet ministers, can also engage in solidarity in the same way as their constituents, they also have additional responsibilities in virtue of their public role and status as elected representatives of their communities.

These responsibilities include things like enacting legislation viagra street price which establishes and maintains institutions and programmes which promote and protect health. Such actions protect the health of their constituents, and they enable those constituents to more effectively engage in solidarity with their peers, by providing the systems necessary to do so most effectively, and guidance as to the reasons for so doing. It is therefore particularly important that elected officials engage in solidarity with their constituents in this manner because individual citizens viagra street price lack the capacity to establish and govern public health institutions, and more importantly, have deferred authority to do these things to those in government through the democratic process.The delivery and maintenance of effective public health programmes relies on most members of a community engaging in solidarity in a range of ways. To illustrate, vaccination programmes cannot deliver herd immunity without mass participation from community members, but individuals cannot contribute to herd immunity if treatments are prohibitively expensive, or only available at an inaccessible venue. They are also unlikely to viagra street price contribute if they have been misled into believing that treatments are dangerous or unnecessary.

Here, engagement in solidarity is required from both private individuals, who must participate in the programme, and elected officials, who must ensure it is accessible to all members of a community, and provide an epistemic context in which the importance and safety of the programme is widely understood, in order for it to be effective.Solidarity and erectile dysfunction treatmentIn his opening remarks to a press briefing on 18 March 2020, Tedros Adhanom Ghebreyesus, Director-General of WHO stated that “(the) spirit of solidarity must be at the centre of our efforts to defeat erectile dysfunction treatment”.2 Similar statements have also been made by a number of other agencies, each of which have emphasised solidarity’s role as an essential part of an effective public health response.9 Correlatively, many governments have instituted lockdowns, and are enforcing social distancing measures (to greater or lesser extent) in order to limit the spread of . We have all thereby been asked, even instructed, to avoid public gatherings, minimise our contact viagra street price with others and help to protect our neighbours. In so doing, we engage in solidarity with our compatriots.For private individuals, engaging in solidarity with their peers in response to erectile dysfunction treatment is thus very similar to such engagement for public health under normal circumstances—participation in public health programmes, social distancing, community cooperation, and contributing through taxation to the cost of public health efforts and medical research. Elected officials can do these things as individuals, but can also respond in their role as public officials in at least two viagra street price additional ways. First, by collaborating with other governments to share information, and coordinate regional and global public health responses.10 Second, by ensuring that NHS exist and are adequately funded, staffed and equipped to be able to respond to the viagra, and by providing clear information and support to citizens so that they may engage in solidarity with one another.There has been great variation in the extent to which different regions have achieved engagement in solidarity across these vectors.

New Zealand and South Korea both implemented thorough testing and tracing programmes which allowed them to counteract the spread of (and in South Korea, also reduced influenza s), while New Zealand also imposed strict lockdown protocols, going as far as closing its borders.11 12 Equally importantly, officials in both locations acted quickly, and communicated clearly with their communities, ensuring that residents knew how to minimise the viagra street price risk of transmission, and why doing so was important. Individual members of these communities were thus able to engage in interpersonal solidarity, by following lockdown rules, maintaining social distancing, and participating in track and trace programmes, because their governments had proactively established the material and epistemological conditions where such engagement was enabled, empowered and encouraged. By doing so, the New Zealand viagra street price and South Korean governments thus engaged in solidarity with their constituents.In contrast, the current British government’s response to erectile dysfunction treatment lacked the transparency, clarity and urgency which characterised the actions of these more successful nations. First, while the UK and New Zealand each initiated lockdowns in the same week in late March, New Zealand at that stage had only 102 cases of erectile dysfunction treatment, with no deaths, compared with the UK’s total of 5687 cases and 281 deaths.12 13 Correlatively, while South Korea did not enforce a strict lockdown, it had enacted social distancing policies even earlier, at the end of February.11 The risk of ongoing transmission was therefore significantly higher in the UK than in either nation at this time.Second, communication from the current British government was often unclear, and the prime minister and other officials frequently downplayed the severity of the viagra—at one point the prime minister (who was later hospitalised with erectile dysfunction treatment) stated that he would not refrain from shaking hands, and that he had recently shaken hands with everyone in a erectile dysfunction treatment ward.14 In this way, the risks of erectile dysfunction treatment were initially minimised in official communications, creating uncertainty about how to act, and which guidance to follow. Exacerbating this viagra street price issue, where advice was given, it was initially often discretionary, and little material support was made available to enable people to follow it.

For example, on 16 March 2020, people were advised to work from home if possible and avoid social venues, such as pubs and theatres.15 However, this was not mandatory, and social venues were not required to close until 20 March, so some employees were required to work onsite, despite known risks.16Correlatively, no support was initially made available to those who could not work remotely, meaning that choices had to be made between employment and ‘fighting the viagra’. Financial support was later made available, in the form of the government’s job retention scheme, which allowed employers to furlough non-essential workers, the wages of whom would be subsidised by government.17 However, this only covered 80% of employee wages, meaning that many of viagra street price those furloughed would have to live on a reduced income. Likewise, while support has been offered to home owners in the form of mortgage holidays, at the time of writing, renters have not received similar assistance.18Third, the government also initially moved to adopt a strategy that deviated from the recommendations of the WHO, which focused on minimising rates through conventional public health measures, such as active testing, social distancing and increased emphasis on personal hygiene (hand washing, etc).19 In contrast, the government initially endorsed a ‘herd immunity’ strategy, which appeared to focus on allowing approximately 60% of the British population to become infected with the viagra, which would have led to an even higher level of excess mortality.20 Despite the eventual rejection of this strategy in favour of closer adherence to WHO guidelines, at the time of writing the UK has the world’s second highest erectile dysfunction treatment mortality rate.21 Further, the consequences of these policy choices were compounded because of the historical policy context in which they occur. In the last decade the NHS has seen a significant reduction in funding as a result of austerity policies.22 Consequently, many NHS trusts have found it extremely difficult to respond safely and viagra street price effectively to the crisis, because of lack of resources (in terms of people, money and equipment)—the absence of sufficient personal protective equipment for those treating patients with erectile dysfunction treatment being particularly notable.23The current British government’s response to erectile dysfunction treatment therefore deviated significantly from those of nations with more successful responses, and from WHO guidance. In doing so, it established an epistemological and financial context where it was difficult for individuals to afford to follow public health guidelines, or to even know exactly what those guidelines required.

As I argued above, the successful delivery and maintenance of public health programmes requires engagement in solidarity from both private viagra street price individuals, and government officials. Engagement in solidarity by the latter entails legislating for the delivery and management of effective public health programmes, and providing clear guidance for their constituents to follow.Unlike their counterparts in New Zealand and South Korea, the current British government has failed to achieve either of these objectives, though it should be noted, that there have also been high profile instances of individual agents in the UK failing to engage in solidarity with their communities.24 However, these solidarity failures must be considered in context. Arguably some failures of individuals to engage in solidarity may at least in part be attributed to governmental failures to deliver an effective public health viagra street price response to erectile dysfunction treatment, or communicate its importance and requirements. It has been noted, for example, that panic buying and stockpiling can be sensible strategies in times of potential social chaos and market disruption—especially when told by the government that a total social lockdown may imminently limit access to necessities.25 In each of these cases, the individuals concerned do have duties of solidarity (as well as professional duties, in the case of healthcare workers) to their compatriots and communities, and failure to fulfil them may cause harm. However, the costs and challenges of fulfilling those duties have been amplified (and in the case of the professional duties of healthcare workers dangerously so) by the government’s failure to fulfil its own responsibilities of solidarity.ConclusionEffective public health programmes viagra street price cannot rely solely on private individuals always engaging in interpersonal solidarity in an optimal fashion.

Private citizens all operate under epistemological constraints—we may not know of the needs of others with whom we would engage in solidarity if we had more complete information, or we may be honestly mistaken about the best way to engage in solidarity with people we do know about. Alternatively, we may know of the needs of others, but face material constraints which make providing significant assistance viagra street price to them impossible. Governments must therefore engage in solidarity with their constituents by providing the epistemological, institutional, material and financial resources, which compensate for these constraints and thus make interpersonal solidarity possible. By failing to do so, the viagra street price current British government has failed to adequately protect the residents of the UK in a time of crisis. It has thus failed to engage in solidarity with its constituents, and effectively devolved responsibility for action to agents with far less power to deliver an effective response to erectile dysfunction treatment.

Further and importantly, those thus tasked with responding to the viagra are disempowered in part because of the failures of the government.Had the government’s failures in response to erectile dysfunction treatment occurred despite the early adoption of recommended strategies proven to work elsewhere, they would not count as failures of solidarity, but viagra street price of policy—as unfortunate consequences of mistakes made under challenging circumstances, despite a good faith effort to achieve the best possible outcome. The government’s actions became failures of solidarity when it ignored compelling and accessible information about how best to respond to the crisis, and did not take actions that they could and should have taken. Further, by failing to provide either definitive rules, or sufficient material and financial support, the government devolved responsibility for responding to the crisis to their constituents and expected them to each individually act in the correct manner viagra street price to prevent the spread of —an unrealistic expectation. As discussed above, private individuals operate under significantly stricter financial, social and epistemological constraints than their elected representatives, constraints which in this instance were exacerbated by the actions of those in power. Even under ideal conditions (that is, in the absence of material and epistemological constraints), reliance on mass individual choices delivering viagra street price an appropriate response to erectile dysfunction treatment would not be an effective strategy.

To rely on such a strategy where such constraints are present is mistaken, and arguably avoidably so. It is also a dereliction of the government’s responsibilities to its constituents.Importantly therefore, the government’s actions represent more than mere failure to adequately protect its viagra street price constituents. By devolving responsibility for action to those without sufficient power to act, the government’s actions should be recognised both as a failure of solidarity, and as a dereliction of it. Indeed, where engagement in solidarity by the government has occurred, it has frequently been delayed, insufficient or reluctantly provided, contributing to the significant excess viagra street price mortality and morbidity experienced by the UK.21A government which fails to engage in solidarity with its constituents, makes an implicit statement about the nature of the relationship between itself and the rest of society. In doing so, and in abdicating their responsibilities to their constituents while simultaneously expecting them to collectively deliver an effective response to erectile dysfunction treatment, they redefine that relationship, from being one of elected representatives and constituents, to one of rulers and ruled.There are two ways to interpret the phrase ‘solidarity is for other people’.

First, it can be read as a statement of closeness and relationality—an expression of the understanding that viagra street price solidarity is something we engage in to assist or benefit other people with whom we identify. Second, it can be understood as an assertion that the speaker holds themselves apart from other people—a claim that solidarity is something that other people should or may do, but that is not something with which the speaker is concerned. Sadly, recent events suggest that we must give serious consideration to the idea that it is this second interpretation which more accurately reflects the attitudes of the British government at this time.AcknowledgmentsThe author thanks Dr Agomoni Ganguli-Mitra for her very helpful comments on an earlier version of this paper..

In this issue of the Journal of Medical Ethics arguments are cogently made that sustainability and solidarity should be considered http://www.ec-schloessel-ostwald.ac-strasbourg.fr/?p=1474 as core medical ethical principles, and that more explicit attention should be given to the complex context in which a decision 100mg viagra for sale is made.Munthe et al propose that sustainability should become an established principle for justifying healthcare resource allocation, and should be an explicit factor in procuring drugs and other resources.1 They argue that the current operational norms which guide decision making (need, prognosis, equal treatment and cost-effectiveness) can lead to what they call ‘negative dynamics’. The gradual depletion of resource available for healthcare.They illustrate this first by examining some well recognised examples of ‘positive dynamics’ which are considered in health policy. Immunisation programmes are funded because lead to reduction or absence of disease in the 100mg viagra for sale population, thus freeing up resource for other uses. Public health measures are offset by future cost reductions or income increases for healthcare via reduction of sick leave.‘Negative dynamics’ however, are not routinely considered in operational decisions and they persuasively argue that they should be.

Resource depletion (not only fiscal resource, but environmental and human resource) has a negative effect on future cycles 100mg viagra for sale of healthcare. As an illustrative example, they discuss the emission of resistance-driving residue in the production of antibiotics. The accepted 100mg viagra for sale principles, particularly of cost effectiveness, drive producers to make antibiotics cheaply, without consideration of gradual contribution to antibiotic resistance. If a principle of sustainability was included when considering procurement, subsidy and prioritisation, this would provide an incentive to change production practices.

This argument can be extended to many aspects of the healthcare 100mg viagra for sale. System including how we recruit, train and treat our staff. How we invest in 100mg viagra for sale infrastructure and how we plan for viagras. Munthe et al go on to provide a robust definition of their sustainability principle, and to address possible objections.

It is an excellent example of reasoned ethical argument which has the potential to change clinical practice.With the roll out of vaccinations for 100mg viagra for sale erectile dysfunction treatment across the globe, Julian Savulescu proposes an algorithm for when mandatory vaccination might be ethically justified.2 Drawing and expanding upon the 2007 Nuffield Council of Bioethics report he suggests that four criteria are required. 1. There is 100mg viagra for sale a grave threat to public health 2. The treatment is safe and effective 3.

Mandatory vaccination has a 100mg viagra for sale superior cost/benefit profile compared with other alternatives 4. The level of coercion is proportionate. Discussing the value judgement associated with each criterion, he concludes that, at least 100mg viagra for sale initially (where uncertainty around safety is greater), mandatory vaccination for erectile dysfunction treatment would be ethically problematic.He goes on to explore alternative approaches, including non-financial (eg, immunisation passports) and financial incentives. He argues that individuals could essentially be paid for the risk they are undertaking (by being early adopters of a treatment) for societal benefit, but to do this government would need to be ‘transparent, explicit and comprehensive in disclosure of data’, a standard which unfortunately has not always (or even often?.

) been 100mg viagra for sale kept. The danger that payment might signal a lack of confidence in safety is real. Clearly payment should only be offered 100mg viagra for sale for a treatment which was considered safe enough to be used in any circumstances. Payment for a treatment which was not considered safe without payment would not be morally acceptable.

Payment may also erode the sense of solidarity that people feel 100mg viagra for sale when contributing to societal well-being. To ensure that this was maintained he suggests the option of ‘donating back’ the fee to the NHS could be made available. People could be rewarded for taking the treatment with an increasing sense of civic duty as they not only protect themselves and the vulnerable, but contribute to the (fiscal) sustainability of the health service which treats them.While Savulescu acknowledges the worth of 100mg viagra for sale solidarity, Avery Kolers proposes that solidarity plays not just an auxillary part in the interests of acknowledged bioethical values (justice, beneficence etc) but has a freestanding role, which should be independently assessed.3 He acknowledges that solidarity per se is not valuable. There is solidarity, he notes, among a firing squad and within a terrorist cell.

He develops Prainsack and Buyx metaphor of solidarity as the putty of justice4 100mg viagra for sale and suggests five individually necessary and sufficient conditions of morally valuable solidarity. It must be (1) norm grounded (2) acknowledged (3) political (4) action and (5) on others’ behalf. He suggests that solidarity (with X) is morally required ‘when it constitutes equitable treatment of X such as to countermand or 100mg viagra for sale resist inequitable treatment of X’. He notes that moral dilemmas may arise where solidarity with X may lead to inequitable treatment of Y and emphasises that solidarity with the most vulnerable in society will help address inequities in healthcare and in healthcare institutions.The complexities and competing moral demands of healthcare institutions, and primary care in particular, are explored by Spicer et al, who question the use of normative moral theories to determine the ‘best’ actions.5 They argue that the context in which ethical decisions are made is not sufficiently acknowledged.

If complex contextual factors are not considered, then predictions about outcomes will be flawed, as will the resulting ethical analyses.Examples of contextual factors which might influence decision-making include power relations within the staff and external regulators (including achieving externally determined quality markers and ‘standard’ practice) and the need to maintain both group and individual professional identities.It is often 100mg viagra for sale helpful to peel back the layers of complexity in order to reveal a specific ethical question. Before coming to a conclusion, however, we must remember to reapply the layers and reconsider the question in the context of its complex environment. Integrating this proposal with others in the journal, this might include considerations of sustainability and solidarity.IntroductionWhile the role and importance of solidarity has been the focus of long-running and extensive debate surrounding public health ethics and practice,1 the erectile dysfunction treatment viagra has cast this debate into even starker relief.2 In doing so, it has emphasised the particular importance 100mg viagra for sale of solidarity for the delivery of effective public health programmes by highlighting the potentially disastrous consequences of its absence. In this paper I examine these consequence with reference to the response of the current British government to erectile dysfunction treatment which failed to deliver an effective public health response to the crisis.

I argue that this response represents mismanagement of a public health crisis, and a rejection of important democratic norms and values.Defining solidaritySolidarity has a wide range of definitions in academic discourse, with its precise features being the subject of heated debate.3 4 Historically, solidarity has been seen as emerging most readily, and most often between persons sharing relatively stable, deeply ingrained qualities, such as shared membership of a state or religious group,5 or commitment to shared political ideals and objectives.6 7 More recently, it has been suggested that more transient, or less deeply ingrained features of persons may serve as the basis for acts of solidarity, and at least short-term solidarity relationships.4 On a larger scale, it has also been suggested that recognition of shared vulnerability in the face of 100mg viagra for sale global threats to health, such as climate change and antimicrobial resistance, may serve as a catalyst for solidarity between nations and peoples.8 As I explain below, this perspective is particularly relevant to the current viagra context.2In this paper I rely mainly on the definition of solidarity offered by Prainsack and Buyx, who define solidarity as ‘enacted commitments to accept costs to assist others with whom a person or persons recognise similarity in a relevant respect’.4 Therefore, solidarity describes what it is that we do when we assist, benefit or support other people because we recognise some form of relevant similarity or connection with/to them. Thus solidarity is active, in that it is something we do, not merely a feeling or attitude. It is also egalitarian, with motivation for action being grounded in recognition of what is shared between parties, not in what distinguishes them.3 Finally, acting in solidarity also involves incurring of costs of some kind, though these may be extremely minimal, or be counterbalanced by the benefits of a given 100mg viagra for sale solidarity action.Prainsack and Buyx argue that there are three main ‘tiers’ of solidaristic action. Interpersonal, group and institutional solidarity.4 The first of these tiers describes what happens between individual persons.

For example, Prainsack and Buyx suggest that giving up one’s seat on 100mg viagra for sale a crowded bus for a pregnant fellow passenger is an act of solidarity when based on recognition of shared experience of discomfort while standing during pregnancy.4 The second tier ‘comprises manifestations of a shared commitment to carry costs to assist others with whom people consider themselves bound together through at least one similarity in a relevant respect’. These group solidarities occur when many individuals share a similar specific context, and engage in actions to benefit others with whom the context is shared. Such solidarity is informal, though 100mg viagra for sale it may also be heavily normalised within a given community, such that it forms an expectation of behaviour.Tier 3 solidarity comprises formalised, or legally mandated expectations of behaviour. Here, solidarity is fully institutionalised, ‘in the form of legally enforceable norms’,4 such as progressive tax systems and welfare state arrangements.

For example, the British National Health Service (NHS) exemplifies institutionalised 100mg viagra for sale solidarity, because it is funded through taxation and provides healthcare to citizens and legal residents of the UK, regardless of their ability to pay. According to Prainsack and Buyx, these three tiers of solidarity are closely connected, with tier 3 solidarity typically emerging from solidarity at tiers 1 and 2. Correlatively, Sangiovanni discusses the participation in collaborative institutions 100mg viagra for sale as solidaristic practice when he argues that solidarity is grounded in ‘our joint action as authors of political and social institutions’.7 Thus, for Sangiovanni solidarity is something which emerges from shared participation in the construction http://mccarthyschoolofirishdance.com/ and enactment of civic society. Solidarity can therefore be interpreted in a range of ways—as the act of carrying costs for relevantly similar others, ‘standing up for’, ‘standing up with’ and ‘standing up as’’ those persons with whom solidarity is identified,3 or the act of working together for a shared goal.7 Regardless of the precise definition adopted, at least basic solidarity, as active engagements in interpersonal and/or institutional egalitarian relationality, by all or most members of a group is fundamentally necessary for the existence and functioning of any community—as I explain below, it is particularly important in democracies.Solidarity and public healthIn normal circumstances, private individuals can engage in interpersonal and group solidarity in the context of public health provision, by avoiding social interaction when sick and helping others to do the same, by purchasing groceries for an ill neighbour, for example.

Individuals can engage in 100mg viagra for sale tier 3 solidarity by participating in institutions which promote and protect public and individual health. For example, participation in fair taxation schemes can help fund health and welfare programmes, such as the British NHS, ensuring the accessibility of these services to all members of a given community, thereby contributing to public health and individual well-being.Correlatively, while elected and appointed governmental officials, such as cabinet ministers, can also engage in solidarity in the same way as their constituents, they also have additional responsibilities in virtue of their public role and status as elected representatives of their communities. These responsibilities include things like enacting legislation 100mg viagra for sale which establishes and maintains institutions and programmes which promote and protect health. Such actions protect the health of their constituents, and they enable those constituents to more effectively engage in solidarity with their peers, by providing the systems necessary to do so most effectively, and guidance as to the reasons for so doing.

It is 100mg viagra for sale therefore particularly important that elected officials engage in solidarity with their constituents in this manner because individual citizens lack the capacity to establish and govern public health institutions, and more importantly, have deferred authority to do these things to those in government through the democratic process.The delivery and maintenance of effective public health programmes relies on most members of a community engaging in solidarity in a range of ways. To illustrate, vaccination programmes cannot deliver herd immunity without mass participation from community members, but individuals cannot contribute to herd immunity if treatments are prohibitively expensive, or only available at an inaccessible venue. They are also unlikely to contribute if they have been 100mg viagra for sale misled into believing that treatments are dangerous or unnecessary. Here, engagement in solidarity is required from both private individuals, who must participate in the programme, and elected officials, who must ensure it is accessible to all members of a community, and provide an epistemic context in which the importance and safety of the programme is widely understood, in order for it to be effective.Solidarity and erectile dysfunction treatmentIn his opening remarks to a press briefing on 18 March 2020, Tedros Adhanom Ghebreyesus, Director-General of WHO stated that “(the) spirit of solidarity must be at the centre of our efforts to defeat erectile dysfunction treatment”.2 Similar statements have also been made by a number of other agencies, each of which have emphasised solidarity’s role as an essential part of an effective public health response.9 Correlatively, many governments have instituted lockdowns, and are enforcing social distancing measures (to greater or lesser extent) in order to limit the spread of .

We have all thereby been asked, even instructed, to avoid public gatherings, minimise our contact 100mg viagra for sale with others and help to protect our neighbours. In so doing, we engage in solidarity with our compatriots.For private individuals, engaging in solidarity with their peers in response to erectile dysfunction treatment is thus very similar to such engagement for public health under normal circumstances—participation in public health programmes, social distancing, community cooperation, and contributing through taxation to the cost of public health efforts and medical research. Elected officials can do these things as individuals, but can also respond in their role as public officials in at 100mg viagra for sale least two additional ways. First, by collaborating with other governments to share information, and coordinate regional and global public health responses.10 Second, by ensuring that NHS exist and are adequately funded, staffed and equipped to be able to respond to the viagra, and by providing clear information and support to citizens so that they may engage in solidarity with one another.There has been great variation in the extent to which different regions have achieved engagement in solidarity across these vectors.

New Zealand and South Korea both implemented thorough testing and tracing programmes which allowed them to counteract the spread of (and in South Korea, also reduced influenza s), while New Zealand also imposed strict lockdown protocols, going as far as closing its borders.11 12 Equally importantly, officials in both locations acted quickly, and communicated clearly with their communities, ensuring that 100mg viagra for sale residents knew how to minimise the risk of transmission, and why doing so was important. Individual members of these communities were thus able to engage in interpersonal solidarity, by following lockdown rules, maintaining social distancing, and participating in track and trace programmes, because their governments had proactively established the material and epistemological conditions where such engagement was enabled, empowered and encouraged. By doing so, the New Zealand and South Korean governments thus engaged in solidarity with their constituents.In contrast, the current British government’s response to erectile dysfunction treatment lacked the transparency, clarity and urgency which characterised the actions 100mg viagra for sale of these more successful nations. First, while the UK and New Zealand each initiated lockdowns in the same week in late March, New Zealand at that stage had only 102 cases of erectile dysfunction treatment, with no deaths, compared with the UK’s total of 5687 cases and 281 deaths.12 13 Correlatively, while South Korea did not enforce a strict lockdown, it had enacted social distancing policies even earlier, at the end of February.11 The risk of ongoing transmission was therefore significantly higher in the UK than in either nation at this time.Second, communication from the current British government was often unclear, and the prime minister and other officials frequently downplayed the severity of the viagra—at one point the prime minister (who was later hospitalised with erectile dysfunction treatment) stated that he would not refrain from shaking hands, and that he had recently shaken hands with everyone in a erectile dysfunction treatment ward.14 In this way, the risks of erectile dysfunction treatment were initially minimised in official communications, creating uncertainty about how to act, and which guidance to follow.

Exacerbating this issue, where advice was given, it was initially often discretionary, and little material support was made available to enable 100mg viagra for sale people to follow it. For example, on 16 March 2020, people were advised to work from home if possible and avoid social venues, such as pubs and theatres.15 However, this was not mandatory, and social venues were not required to close until 20 March, so some employees were required to work onsite, despite known risks.16Correlatively, no support was initially made available to those who could not work remotely, meaning that choices had to be made between employment and ‘fighting the viagra’. Financial support was later made available, in the form of the government’s job retention scheme, which allowed employers to furlough non-essential workers, the wages of whom would be subsidised by government.17 However, this only covered 80% of employee wages, meaning that many of those furloughed would have to live on a reduced income 100mg viagra for sale. Likewise, while support has been offered to home owners in the form of mortgage holidays, at the time of writing, renters have not received similar assistance.18Third, the government also initially moved to adopt a strategy that deviated from the recommendations of the WHO, which focused on minimising rates through conventional public health measures, such as active testing, social distancing and increased emphasis on personal hygiene (hand washing, etc).19 In contrast, the government initially endorsed a ‘herd immunity’ strategy, which appeared to focus on allowing approximately 60% of the British population to become infected with the viagra, which would have led to an even higher level of excess mortality.20 Despite the eventual rejection of this strategy in favour of closer adherence to WHO guidelines, at the time of writing the UK has the world’s second highest erectile dysfunction treatment mortality rate.21 Further, the consequences of these policy choices were compounded because of the historical policy context in which they occur.

In the last decade the NHS has seen a significant 100mg viagra for sale reduction in funding as a result of austerity policies.22 Consequently, many NHS trusts have found it extremely difficult to respond safely and effectively to the crisis, because of lack of resources (in terms of people, money and equipment)—the absence of sufficient personal protective equipment for those treating patients with erectile dysfunction treatment being particularly notable.23The current British government’s response to erectile dysfunction treatment therefore deviated significantly from those of nations with more successful responses, and from WHO guidance. In doing so, it established an epistemological and financial context where it was difficult for individuals to afford to follow public health guidelines, or to even know exactly what those guidelines required. As I argued above, the successful delivery and maintenance of public health 100mg viagra for sale programmes requires engagement in solidarity from both private individuals, and government officials. Engagement in solidarity by the latter entails legislating for the delivery and management of effective public health programmes, and providing clear guidance for their constituents to follow.Unlike their counterparts in New Zealand and South Korea, the current British government has failed to achieve either of these objectives, though it should be noted, that there have also been high profile instances of individual agents in the UK failing to engage in solidarity with their communities.24 However, these solidarity failures must be considered in context.

Arguably some failures of individuals to engage in 100mg viagra for sale solidarity may at least in part be attributed to governmental failures to deliver an effective public health response to erectile dysfunction treatment, or communicate its importance and requirements. It has been noted, for example, that panic buying and stockpiling can be sensible strategies in times of potential social chaos and market disruption—especially when told by the government that a total social lockdown may imminently limit access to necessities.25 In each of these cases, the individuals concerned do have duties of solidarity (as well as professional duties, in the case of healthcare workers) to their compatriots and communities, and failure to fulfil them may cause harm. However, the costs and challenges of fulfilling those duties have been amplified (and in the case of the professional duties of healthcare workers dangerously so) by the government’s failure to fulfil its own responsibilities of solidarity.ConclusionEffective public health programmes cannot rely solely on private individuals 100mg viagra for sale always engaging in interpersonal solidarity in an optimal fashion. Private citizens all operate under epistemological constraints—we may not know of the needs of others with whom we would engage in solidarity if we had more complete information, or we may be honestly mistaken about the best way to engage in solidarity with people we do know about.

Alternatively, we may know of the needs of others, but face material constraints which make providing significant assistance to them impossible 100mg viagra for sale. Governments must therefore engage in solidarity with their constituents by providing the epistemological, institutional, material and financial resources, which compensate for these constraints and thus make interpersonal solidarity possible. By failing to do so, the current British government has failed to adequately protect the residents of 100mg viagra for sale the UK in a time of crisis. It has thus failed to engage in solidarity with its constituents, and effectively devolved responsibility for action to agents with far less power to deliver an effective response to erectile dysfunction treatment.

Further and importantly, those thus tasked with responding to the viagra are disempowered in part because of the failures of the government.Had the government’s failures in response to erectile dysfunction treatment occurred despite the early adoption of recommended strategies proven to work elsewhere, they would not count as failures of solidarity, but of policy—as unfortunate consequences of mistakes made under challenging circumstances, despite a good faith effort to achieve the best 100mg viagra for sale possible outcome. The government’s actions became failures of solidarity when it ignored compelling and accessible information about how best to respond to the crisis, and did not take actions that they could and should have taken. Further, by failing to provide either definitive rules, or sufficient material and financial support, the government devolved responsibility for responding to the crisis to their constituents and 100mg viagra for sale expected them to each individually act in the correct manner to prevent the spread of —an unrealistic expectation. As discussed above, private individuals operate under significantly stricter financial, social and epistemological constraints than their elected representatives, constraints which in this instance were exacerbated by the actions of those in power.

Even under ideal conditions (that is, in the absence of material and epistemological constraints), reliance on 100mg viagra for sale mass individual choices delivering an appropriate response to erectile dysfunction treatment would not be an effective strategy. To rely on such a strategy where such constraints are present is mistaken, and arguably avoidably so. It is also a dereliction of the government’s responsibilities to its constituents.Importantly therefore, the government’s actions represent more than mere 100mg viagra for sale failure to adequately protect its constituents. By devolving responsibility for action to those without sufficient power to act, the government’s actions should be recognised both as a failure of solidarity, and as a dereliction of it.

Indeed, where engagement in 100mg viagra for sale solidarity by the government has occurred, it has frequently been delayed, insufficient or reluctantly provided, contributing to the significant excess mortality and morbidity experienced by the UK.21A government which fails to engage in solidarity with its constituents, makes an implicit statement about the nature of the relationship between itself and the rest of society. In doing so, and in abdicating their responsibilities to their constituents while simultaneously expecting them to collectively deliver an effective response to erectile dysfunction treatment, they redefine that relationship, from being one of elected representatives and constituents, to one of rulers and ruled.There are two ways to interpret the phrase ‘solidarity is for other people’. First, it can be read as a statement of closeness and 100mg viagra for sale relationality—an expression of the understanding that solidarity is something we engage in to assist or benefit other people with whom we identify. Second, it can be understood as an assertion that the speaker holds themselves apart from other people—a claim that solidarity is something that other people should or may do, but that is not something with which the speaker is concerned.

Sadly, recent events suggest that we must give serious consideration to the idea that it is this second interpretation which more accurately reflects the attitudes of the British government at this time.AcknowledgmentsThe author thanks Dr Agomoni Ganguli-Mitra for her very helpful comments on an earlier version of this paper..

Is viagra safe

€‚Listen to the podcast associated with this article, which can also be found at ESC CardioTalk https://www.escardio.org/The-ESC/Whatwe-do/news/ESC-Cardio-Talk https://kingdomconnection.eu/can-you-buy-levitra-without-a-prescription/ This editorial refers to ‘Time-to-treatment initiation of colchicine and cardiovascular outcomes after myocardial is viagra safe infarction in the Colchicine Cardiovascular Outcomes Trial (COLCOT)’†, by N. Bouabdallaoui et al., on page 4092. Virchow’s prophecyThe is viagra safe late Rudolf L.C.

Virchow (1821–1902) made a visionary statement when he wrote in one of his textbooks ‘Atherosclerosis is a chronic inflammation induced by cholesterol’.1 It did not have much impact for several decades until the Russian scientist Nikolay Nikolaevich Anichkov (1885–1964) showed in his seminal experiments in the rabbit aorta that a high fat diet induces cholesterol-rich plaques.2 Thereafter, research focused on cholesterol rather than inflammation, with crucial epidemiological studies in Framingham and worldwide confirming an association of plasma lipid levels with the complications of atherosclerosis, i.e. Myocardial infarction, stroke, and sudden is viagra safe and premature death.3 The final proof of the cholesterol hypothesis came with the 4S trial using simvastatin in patients with coronary artery disease, demonstrating an impressive reduction of major cardiovascular events with pharmacological cholesterol lowering.4 Rediscovering inflammationHowever, there was a remaining cardiovascular risk, and this led to the rediscovery of the true meaning of Virchow’s seminal statement. First of all, it appeared from experimental studies that oxidized or otherwise modified cholesterol rather than native LDL-cholesterol (LDL-C)5,6 was involved and that dysfunctional HDL-C lost its protective function.7,8 The expression of adhesion molecules and, in turn, the presence of white blood cells such as monocytes, macrophages, and T cells in atherosclerotic plaques9 and the occluding thrombus in acute coronary syndromes (ACS)10 further corroborated the concept that inflammation might play a role.

In 1994, the group of Attilio Maseris showed that acute phase proteins such as C-reactive protein (CRP) and serum amyloid A (SAA) predicted future cardiovascular events in patients with unstable angina.11 This observation was soon extended by Charles Hennekens and Paul Ridker to healthy individuals.12 In individuals at high cardiovascular risk with elevated CRP, but normal or midly elevated cholesterol, rosuvastatin lowered not only CRP, but also major cardiovascular events (MACE).13 Indeed, a mild anti-inflammatory action of statins had previously been is viagra safe demonstrated in small experimental trials. Thus, Virchow’s vision was indeed prophetic. However, how can this information be used clinically to the benefit of patients?.

Inflammation and acute coronary syndromesA patient population in which inflammation is particularly important are is viagra safe those with ACS. Indeed, at the time of such an acute event, CRP and SAA plasma levels are several magnitudes higher than in patients with chronic coronary syndromes.10 Thus, it seems that ACS are associated with an inflammatory burst. Of note, is viagra safe inflammation is particularly high at the site of acute coronary occlusion, with an array of cytokines expressed, among them interleukins10 acting on Toll-like receptors on white blood cells in a vicious cycle leading to an acute inflammatory storm.14 In this context, inflammation is a major trigger of plaque vulnerability, erosion, or rupture, and eventually coronary occlusion.

After reperfusion, as occurs after successful primary percutaneous coronary intervention, inflammation importantly contributes to reperfusion injury also in the myocardium15 and in turn increases infarct size and scar formation, leading to left ventricular remodelling16 and MACE. Anti-inflammatory therapy as a new strategyBased on these data and insights into the molecular mechanisms of ACS, inflammation became the new therapeutic is viagra safe frontier. After a few smaller proof-of-concept studies, the CANTOS trial using the interleukin-1β (IL-β) antagonist canakinumab proved the causal association of inflammation with MACE after ACS.17 Indeed, after 4 years, canakinumab reduced MACE (i.e.

Non-fatal myocardial infarction or stroke and cardiovascular death) overall by ∼15% 17 and by 26% is viagra safe in those with an on-treatment CRP level <2 mg/L.18 Interestingly, canakinumab also reduced the occurrence of cancer, and in particular lung cancer, in these patients.19 The latter finding led the sponsor Novartis to decide to develop canakinumab for this indication rather than in cardiac patients.Thus, at this point, the clinical implementation of anti-inflammation came to a halt until recently when the results of the COLCOT trial were published. In this trial, patients who had survived an ACS were randomized within 30 days after the event to either placebo or colchicine at a low dose of 0.5 mg daily and were followed-up for a median of 2 years.20 Impressively, colchicine led to a 23% reduction of the primary endpoint of death, rescucitated cardiac arrest, ACS, stroke, and urgent hospitalization for angina requiring revascularization (however with the latter beiing the primary driver of the effect). Given the early inflammatory burst at the time of ACS, it remained unclear—as has been the case in CANTOS—whether very early anti-inflammation might be even more advantageous or possibly rather dangerous.

This question has is viagra safe now been addressed in the manuscript by Bouabdallaoui et al. In the current issue of the European Heart Journal.21 They grouped the patients enrolled in COLCOT into three groups that had received investigational drugs (i.e. Colchicine or placebo) within the first 3, 4–7, or 8 or is viagra safe more days.

Importantly, after a mean follow-up of 23 months, there was an amazing significant reduction of 48% in the primary endpoint in those receiving colchicine within 3 days or less, but only of 4–18% in those receiving the drug at a later timepoint. Thus, anti-inflammatory therapy seems is viagra safe to work best the sooner it is provided after ACS. Given the fact that inflammation is most pronounced in the very early phase of an acute myocardial infarction, these results make a lot of sense.

Learning from goutWhat might be the mechanism of action of colchicine which traditionally is viagra safe is used in the management of gout?. The mechanisms of action of colchicine are obviously multiple and not completely understood.22 First of all, colchicine binds to free tubulin, an αβ heterodimer initially identified as the cellular colchicine-binding protein that forms microtubules upon polymerization and interacts with many regulatory cellular proteins (Figure 1). Thereby colchicine inhibits cell migration and cytokine release, particularly by white blood cells.

Colchicine also modulates superoxide production by leucocytes23 which is in part responsible for the inhibition of neutrophil adhesion, extravasation, and recruitment by altering neutrophil L-selectin is viagra safe expression and endothelial cell E-selectin distribution, and suppressing the release of the chemotactic leukotriene B4. Whether all of these effects are secondary to the impact of colchicine on microtubules remains to be determined. Importantly, however, colchicine inhibits the Nod-Like Receptor Protein 3 (NLRP3) inflammasome is viagra safe (while urate crystals activate i)t,24 thereby suppressing caspase-1 activation and the subsequent release of IL-1β and IL-18.

Figure 1). As the NLRP3 inflammasome is expressed in the myeloid lineage,25 colchicine appears to mainly interfere with neutrophils and monocytes and is viagra safe macrophages, i.e. The innate immune system that is involved in ACS, rather than the adaptive immune system.

Figure 1Molecular effects of is viagra safe colchicine in white blood cells via tubulin and microtubuli as well as Nod-Like Receptor Protein 3 (NLRP3) inflammasome. Inset left, urate crystals. Inset right, cholesterol crystals (modified from Imazio M, Gaita F.

Heart April 2016 Vol 102 No 8).Figure 1Molecular effects of colchicine in white is viagra safe blood cells via tubulin and microtubuli as well as Nod-Like Receptor Protein 3 (NLRP3) inflammasome. Inset left, urate crystals. Inset right, cholesterol crystals (modified from Imazio M, Gaita F is viagra safe.

Heart April 2016 Vol 102 No 8). Colchicine after acute coronary syndromes? is viagra safe. Should we now use colchicine in the very early phase of ACS as a remedy to reduce MACE?.

First of all, colchicine is cheap and, particularly at the low dose used is viagra safe in COLCOT, relatively well tolerated. Indeed, in the COLCOT trial, gastrointestinal side effects such as nausea and flatulence were quite rare, with 2.4% vs. 1.2% with placebo.

Obviously, as any is viagra safe anti-inflammatory drug, colchicine increases the risk of . Pneumonia was rare, but indeed more common, with 0.9% vs. 0.4% with colchicine is viagra safe and placebo, respectively.

Should we therefore avoid prescribing colchicine for the elderly who are at risk of pneumonia or provide them with pneumococcal vaccination?. Indeed, acute s may precipitate myocardial infarction, while influenza, is viagra safe tetanus, and pneumococcal vaccinations do not produce a detectable increase in this risk, but may actually be protective.26 As such, this may be a reasonable precaution in this context.A second question is whether colchicine would be suitable for all ACS patients or only for those with signs of excessive inflammation?. Indeed, not all patients with ACS have signs of inflammation.

Typically, out-of-the-blue infarctions are triggered by other stimuli (such as shear stress, pulsatility, spasm, etc.), while in heralded infarction inflammation plays a primary role.10,27 Unfortunatly, CRP or SAA were not assessed in COLCOT and hence a more personalized use of this drug awaits further studies. Overall, however, the main COLCOT trial and now this important is viagra safe subanalysis open the door for an even more effective treatment of patients with ACS with remaining inflammatory risk.Conflict of interest. There are no conflicts of interest for this Editorial.

However, the author has received grants for his ACS research from Amgen, AstraZeneca, Eli Lilly, Medtronic, and Sanofi, is viagra safe and honoraria for consulting and lecturing from Amgen and Sanofi.The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. References1Virchow R. Die Cellularpathologie in ihrer Begründung auf physiologische und pathologische Gewebelehre A is viagra safe.

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J Am Coll Cardiol 2016;67:2050–2060.17Ridker PM, Everett BM, Thuren T, MacFadyen JG, Chang WH, Ballantyne C, Fonseca F, Nicolau J, Koenig W, Anker SD, Kastelein JJP, Cornel JH, Pais P, Pella D, Genest J, Cifkova R, Lorenzatti A, Forster T, Kobalava Z, Vida-Simiti L, Flather M, Shimokawa H, Ogawa H, Dellborg M, Rossi PRF, Troquay RPT, Libby P, Glynn RJ. Antiinflammatory therapy with canakinumab for atherosclerotic disease. N Engl J Med 2017;377:1119–1131.18Ridker PM, MacFadyen JG, Everett BM, Libby P, Thuren T, Glynn RJ.

Relationship of C-reactive protein reduction to cardiovascular event reduction following treatment with canakinumab. A secondary analysis from the CANTOS randomised controlled trial. Lancet 2018;391:319–328.19Ridker PM, MacFadyen JG, Thuren T, Everett BM, Libby P, Glynn RJ.

Effect of interleukin-1β inhibition with canakinumab on incident lung cancer in patients with atherosclerosis. Exploratory results from a randomised, double-blind, placebo-controlled trial. Lancet 2017;390:1833–1842.20Tardif JC, Kouz S, Waters DD, Bertrand OF, Diaz R, Maggioni AP, Pinto FJ, Ibrahim R, Gamra H, Kiwan GS, Berry C, López-Sendón J, Ostadal P, Koenig W, Angoulvant D, Grégoire JC, Lavoie MA, Dubé MP, Rhainds D, Provencher M, Blondeau L, Orfanos A, L’Allier PL, Guertin MC, Roubille F.

Efficacy and safety of low-dose colchicine after myocardial infarction. N Engl J Med 2019;381:2497–2505.21Bouabdallaoui N, Tardif JC, Waters DD, Pinto FJ, Maggioni AP, Diaz R, Berry C, Koenig W, Lopez-Sendon J, Gamra H, Kiwan GS, Blondeau L, Orfanos A, Ibrahim R, Grégoire JC, Dubé MP, Samuel M, Morel O, Lim P, Bertrand OF, Kouz S, Guertin MC, L’Allier PL, Roubille F. Time-to-treatment initiation of colchicine and cardiovascular outcomes after myocardial infarction in the Colchicine Cardiovascular Outcomes Trial (COLCOT).

Eur Heart J 2020;41:4092–4099.22Slobodnick A, Shah B, Krasnokutsky S, Pillinger MH. Update on colchicine, 2017. Rheumatology 2018;57(suppl_1):i4–i11.23Chia EW, Grainger R, Harper JL.

Colchicine suppresses neutrophil superoxide production in a murine model of gouty arthritis. A rationale for use of low‐dose colchicine. Br J Pharmacol 2009;153:1288–1295.24Wiendels NJ, Knuistingh Neven A, Rosendaal FR, Spinhoven P, Zitman FG, Assendelft WJ, Ferrari MD.

Chronic frequent headache in the general population. Prevalence and associated factors. Cephalalgia 2006;26:1434–1442.25Mühlhauser I, Sawicki PT, Blank M, Overmann H, Bender R, Berger M.

Prognosis of persons with type 1 diabetes on intensified insulin therapy in relation to nephropathy. J Intern Med 2000;248:333–341.26Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of myocardial infarction and stroke after acute or vaccination.

N Engl J Med 2004;351:2611–2618.27Liuzzo G, Biasucci LM, Gallimore JR, Caligiuri G, Buffon A, Rebuzzi AG, Pepys MB, Maseri A. Enhanced inflammatory response in patients with preinfarction unstable angina. J Am Coll Cardiol 1999;34:1696–1703.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020.

For permissions, please email. Journals.permissions@oup.com.The Green Lane Cardiovascular Research Unit and The Green lane Coordinating Centre in Auckland New ZealandThe Green Lane Cardiovascular Research Unit (CVRU) was formed when Harvey White returned to Green Lane Hospital, Auckland, New Zealand from Boston in 1984 where he was a research fellow at the Brigham and Women’s Hospital. While in Boston, he somehow gained the ‘gene’ for research and writing.

Green Lane was the hospital where Sir Brian Barrett-Boyes and many colleagues had performed pioneering homograft aortic valve replacements and developed techniques of hypothermia for operating on babies with congenital heart disease. There was a focus on high quality clinical care and research.The mission of the CVRU was ‘to do research for improving patient care throughout the world’. The unit began research for three reasons.

To improve patient care, to improve science, and to have fun. From the beginning, the unit undertook both local and international collaborative trials. Local trials were very important.

Between 1987 and 1989, there were three major publications from local trials. One in 1987 was in Circulation on ‘Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction’1 which Dr Eugene Braunwald has called one of the greatest advancements in post-MI management (Braunwald ACC 2013). And two were in the New England Journal of Medicine on thrombolysis and left ventricular function with comparison of streptokinase with placebo, and streptokinase with TPA.2,3It was very clear from the beginning that to make a difference to patient care, large numbers of patients (1000 s) would be needed, to have the statistical power to show benefits and to be able to assess harm.

The only way of doing that was to collaborate, collaborate, and collaborate.International collaboration was first with Australia with Dr Phil Aylward. Phil is an outstanding clinician who brings enormous clinical experience to steering committees in the design and practical undertaking of trials and played a major part in the HERO (Hirulog Early Reperfusion/Occlusion) Trials. And secondly, with Dr Andrew Tonkin and Dr John Simes, also from Australia, on the LIPID (Long-Term Intervention With Pravastatin in Ischaemic Disease) group—a trial showing that pravastatin reduced total mortality in patients with previous myocardial infarction or unstable angina.4 New Zealand contributed over 3000 patients and the collaboration continues with over 20 years follow-up and over 60 publications.

The group also published the first study on prevention of stroke subtypes with statin therapy.5In 1988, an international trial branch was formed as part of CVRU to participate in International trials including the ISIS and Gusto trials. This was initially led by Maggie Scott, former charge nurse of the CCU at Green Lane Hospital. Maggie also coordinated the world-wide HERO-2 trial with 15 000 patients in 27 countries comparing bivalirudin with unfractionated heparin following fibrinolytic therapy6 (Figure 1).

Figure 1The Cardiovascular Research Unit (CVRU) in 1992.Figure 1The Cardiovascular Research Unit (CVRU) in 1992.In 2003, an Academic Research Organisation (ARO) named Green Lane Coordinating Centre Limited (GLCC) was formed offsite from Green Lane Hospital. Olga Bucan from Slovenia was the Director and coordinated the STabilisation of Atherosclerotic plaque By Initiation of darapLadib TherapY (STABILITY) Trial with 15 000 patients in 38 countries.7Dr John French joined as a Senior Cardiologist and Researcher in 1992. John is an enormously hard worker and has numerous publications on coronary flow, LV function, and survival as well as a seminal paper on the importance of factor V Leiden in young patients who had had an MI with normal coronary arteries.8 John left for Australia in 2003 but still closely collaborates on trials and registries.Dr Cheuk-Kit Wong joined CVRU in 1999 and published 25 papers on ECGs from the HERO ECG core laboratory including the first study to show that Q waves on an ECG are more important than door to reperfusion time for prognosis.9The CVRU is now based at Auckland City Hospital as part of the Green Lane Cardiovascular Department.

The research unit continues to deliver excellent clinical trial management. A team of investigators, nurses, and administrators support the current trials which include a mix of international academic and pharmaceutical trials as well as local investigators with national and Auckland Hospital based studies (Figure 2 Group). Figure 2The Cardiovascular Research Unit (CVRU) in 2020.

Standing from L to R. Dr Jithendra Somaratne, Prof Harvey White, Dr Jocelyne Benatar, Prof Ralph Stewart. Sitting from L to R.

Michelle D’Souza, Leah Howell, Cathrine Patten, and Diana Gatland.Figure 2The Cardiovascular Research Unit (CVRU) in 2020. Standing from L to R. Dr Jithendra Somaratne, Prof Harvey White, Dr Jocelyne Benatar, Prof Ralph Stewart.

Sitting from L to R. Michelle D’Souza, Leah Howell, Cathrine Patten, and Diana Gatland.Dr Jocelyne Benatar joined in 2000 and has done a number of studies assessing the effects of dairy food on cardiovascular disease and diet on cardiometabolic syndrome.10 She continues as the principal and co-investigator for a number of nutritional, diabetes, rehabilitation, and cardiovascular trials.Dr Ralph Stewart joined CVRU in 1999 and GLCC in 2003 and has led numerous trials including the recent New Zealand Oxygen Study (Stewart ESC 2019). He along with Ivor Gerber reported the relationship between NT-proBNP levels and the prognosis of patients with aortic valve disease.11Research nurses have been a very important and an integral part of the CVRU and the development of a career pathway and work/life balance has been a primary focus.

The CVRU was one of the first to employ research nurses. The first research nurse was Barbara Williams who had been in charge of the CCU at Green Lane Hospital. Barbara led a study on consent in patient with acute STEMI published in the Lancet.12 Mary Denton was CVRU’s first nurse manager.

Today, nurse co-ordinator Cathrine Patten manages the current trials.Caroline Alsweiler who was a Senior Clinical Research Associate and Clinical Trial Manager became Director of GLCC in 2014. The GLCC works closely with a core group of investigators in New Zealand, Australia, Singapore, Hong Kong, Malaysia, Thailand, Korea, and the Philippines to deliver high quality data (Figure 3), The Mission statement is ‘to improve the health and quality of life of people throughout the world through innovative clinical research’. Together with support from national and international academia, they are dedicated to achieving the highest possible standard in clinical research while maintaining well-established relationships with investigators both nationally and internationally, achieving quick turnaround times for completion of regulatory documents, and ensuring integrity of research data.

The GLCC has been involved with over 70 international clinical trials from Phases II–IV. Figure 3Members of the Green Lane Coordinating Centre (GLCC) in 2019.Figure 3Members of the Green Lane Coordinating Centre (GLCC) in 2019.The CVRU and GLCC have received many acknowledgements and awards. It has to be strongly stressed that these and publications have been a team effort.

In 1998, Harvey was awarded the Prince Mahidol Award for Medicine by the King of Thailand for introducing aspirin and fibrinolytic therapy in 27 developing countries, including China (Figure 4). This award is considered the Nobel Prize of the East and is given for introducing treatments rather than being the first to discover something. Harvey was bestowed a Matai (Chief) title in Samoa in 1994 with a title of ‘La’auli’ the highest peak in the land for his work treating patients as well as working with WHO in Samoa.

Figure 4Harvey receiving the Prince Mahidol Award from the King of Thailand.Figure 4Harvey receiving the Prince Mahidol Award from the King of Thailand.In 2020, the work from CVRU and GLCC was ranked no. 5 in the world across all branches of medicine for publication of RCT-related articles in high-impact-factor medical journals over the past five decades and with the highest collaboration index.13The CVRU and GLCC continue to be very productive with over 20 ongoing trials. The special research interests include management of acute coronary syndromes, antithrombotic management of acute coronary syndromes and atrial fibrillation, biomarkers, secondary prevention of cardiovascular disease, management of cardiovascular disease in the elderly, diabetes, nutrition, rehabilitation, frailty, dyslipidaemia, and registry studies.Over 1000 peer-reviewed manuscripts have been published.

Contributions of the two organizations to multicentre trials have helped develop the evidence base for guidelines for the practice of clinical cardiology. These include the role of troponins in ACS,14 the importance of 0.5 mm ST depression for prognosis in patients with non-STEMI,15 elderly patients should not be denied fibrinolytic therapy,16 the risks of switching antithrombotic therapy,17 the BARC bleeding definition,18 and the Universal definition of MI defining the five types of MI.19Relationships have been very important and one of the wonderful things about collaborating in International trials is meeting and making friends with the most amazing people from the ISIS, Gusto, TIMI, Duke, Leuven, Uppsala, Vigour, ECLA, OASIS, New York University, Montreal, SAMHRI, ODYSSEY, and Cleveland Clinic groups etc. (Figure 5).

Figure 5Members of the Vigour organization at the Uppsala Research Centre from Duke USA, Canada, Sweden, and New Zealand in Uppsala in 2010.Figure 5Members of the Vigour organization at the Uppsala Research Centre from Duke USA, Canada, Sweden, and New Zealand in Uppsala in 2010.A Māori proverb (of the indigenous people of New Zealand) says:‘He aha te mea nui o te aoWhat is the most important thing in the world?. He tangata, he tangata, he tangataIt is the people, it is the people, it is the people’The many people in the two Green Lane organizations (CVRU and GLCC) have had fun, perhaps contributions have been made to science and patient care has also been improved. AcknowledgementsMichelle D'Souza provided editorial and secretarial assistance in the preparation of the manuscript and was funded by The Green Lane Research and Educational Fund (GLREF), Auckland City Hospital.

Dr White gratefully thanks the GLREF for support as the John Neutze Fellow. We would like to thank cardiologists and cardiac surgeons and nurses throughout New Zealand and the world, and patients who have taken part in the clinical trials.Conflict of interest. H.D.W.

Has received grant support paid to the institution and fees for serving on a steering committee from Sanofi-Aventis and Regeneron Pharmaceuticals, for the HEART-FID study from American Regent. For the dal-GenE study from DalCor Pharma UK Inc., for the AEGIS-II study from CSL Behring, for the SCORED trial and the SOLOIST-WHF trial from Sanofi-Aventis Australia Pty Ltd, and for the CLEAR Outcomes Study from Esperion Therapeutics Inc. He was on an Advisory Board for Genentech, Inc.

And received lecture fees from AstraZeneca outside the submitted work. ReferencesReferences are available as supplementary material at European Heart Journal online. Published on behalf of the European Society of Cardiology.

All rights reserved. © The Author(s) 2020. For permissions, please email.

€‚Listen to Can you buy levitra without a prescription the podcast associated with this article, which can also be found at ESC CardioTalk 100mg viagra for sale https://www.escardio.org/The-ESC/Whatwe-do/news/ESC-Cardio-Talk This editorial refers to ‘Time-to-treatment initiation of colchicine and cardiovascular outcomes after myocardial infarction in the Colchicine Cardiovascular Outcomes Trial (COLCOT)’†, by N. Bouabdallaoui et al., on page 4092. Virchow’s prophecyThe 100mg viagra for sale late Rudolf L.C. Virchow (1821–1902) made a visionary statement when he wrote in one of his textbooks ‘Atherosclerosis is a chronic inflammation induced by cholesterol’.1 It did not have much impact for several decades until the Russian scientist Nikolay Nikolaevich Anichkov (1885–1964) showed in his seminal experiments in the rabbit aorta that a high fat diet induces cholesterol-rich plaques.2 Thereafter, research focused on cholesterol rather than inflammation, with crucial epidemiological studies in Framingham and worldwide confirming an association of plasma lipid levels with the complications of atherosclerosis, i.e.

Myocardial infarction, stroke, and sudden and premature death.3 The final proof of 100mg viagra for sale the cholesterol hypothesis came with the 4S trial using simvastatin in patients with coronary artery disease, demonstrating an impressive reduction of major cardiovascular events with pharmacological cholesterol lowering.4 Rediscovering inflammationHowever, there was a remaining cardiovascular risk, and this led to the rediscovery of the true meaning of Virchow’s seminal statement. First of all, it appeared from experimental studies that oxidized or otherwise modified cholesterol rather than native LDL-cholesterol (LDL-C)5,6 was involved and that dysfunctional HDL-C lost its protective function.7,8 The expression of adhesion molecules and, in turn, the presence of white blood cells such as monocytes, macrophages, and T cells in atherosclerotic plaques9 and the occluding thrombus in acute coronary syndromes (ACS)10 further corroborated the concept that inflammation might play a role. In 1994, the group of Attilio Maseris showed that acute phase proteins such as C-reactive protein (CRP) and serum amyloid A (SAA) predicted future cardiovascular events in patients with unstable angina.11 This observation was soon extended by Charles Hennekens 100mg viagra for sale and Paul Ridker to healthy individuals.12 In individuals at high cardiovascular risk with elevated CRP, but normal or midly elevated cholesterol, rosuvastatin lowered not only CRP, but also major cardiovascular events (MACE).13 Indeed, a mild anti-inflammatory action of statins had previously been demonstrated in small experimental trials. Thus, Virchow’s vision was indeed prophetic.

However, how can this information be used clinically to the benefit of patients?. Inflammation and acute coronary syndromesA patient population in 100mg viagra for sale which inflammation is particularly important are those with ACS. Indeed, at the time of such an acute event, CRP and SAA plasma levels are several magnitudes higher than in patients with chronic coronary syndromes.10 Thus, it seems that ACS are associated with an inflammatory burst. Of note, inflammation is particularly high at the site of acute coronary occlusion, with an array of cytokines expressed, among them interleukins10 acting on Toll-like receptors on white blood cells in a 100mg viagra for sale vicious cycle leading to an acute inflammatory storm.14 In this context, inflammation is a major trigger of plaque vulnerability, erosion, or rupture, and eventually coronary occlusion.

After reperfusion, as occurs after successful primary percutaneous coronary intervention, inflammation importantly contributes to reperfusion injury also in the myocardium15 and in turn increases infarct size and scar formation, leading to left ventricular remodelling16 and MACE. Anti-inflammatory therapy as a new 100mg viagra for sale strategyBased on these data and insights into the molecular mechanisms of ACS, inflammation became the new therapeutic frontier. After a few smaller proof-of-concept studies, the CANTOS trial using the interleukin-1β (IL-β) antagonist canakinumab proved the causal association of inflammation with MACE after ACS.17 Indeed, after 4 years, canakinumab reduced MACE (i.e. Non-fatal myocardial infarction or stroke and cardiovascular death) overall by ∼15% 17 and by 26% in those with an 100mg viagra for sale on-treatment CRP level <2 mg/L.18 Interestingly, canakinumab also reduced the occurrence of cancer, and in particular lung cancer, in these patients.19 The latter finding led the sponsor Novartis to decide to develop canakinumab for this indication rather than in cardiac patients.Thus, at this point, the clinical implementation of anti-inflammation came to a halt until recently when the results of the COLCOT trial were published.

In this trial, patients who had survived an ACS were randomized within 30 days after the event to either placebo or colchicine at a low dose of 0.5 mg daily and were followed-up for a median of 2 years.20 Impressively, colchicine led to a 23% reduction of the primary endpoint of death, rescucitated cardiac arrest, ACS, stroke, and urgent hospitalization for angina requiring revascularization (however with the latter beiing the primary driver of the effect). Given the early inflammatory burst at the time of ACS, it remained unclear—as has been the case in CANTOS—whether very early anti-inflammation might be even more advantageous or possibly rather dangerous. This question has now been addressed in the manuscript by Bouabdallaoui et 100mg viagra for sale al. In the current issue of the European Heart Journal.21 They grouped the patients enrolled in COLCOT into three groups that had received investigational drugs (i.e.

Colchicine or placebo) within the first 3, 4–7, 100mg viagra for sale or 8 or more days. Importantly, after a mean follow-up of 23 months, there was an amazing significant reduction of 48% in the primary endpoint in those receiving colchicine within 3 days or less, but only of 4–18% in those receiving the drug at a later timepoint. Thus, anti-inflammatory therapy seems to work best the sooner 100mg viagra for sale it is provided after ACS. Given the fact that inflammation is most pronounced in the very early phase of an acute myocardial infarction, these results make a lot of sense.

Learning from goutWhat might be the mechanism of action of colchicine which traditionally is used in the 100mg viagra for sale management of gout?. The mechanisms of action of colchicine are obviously multiple and not completely understood.22 First of all, colchicine binds to free tubulin, an αβ heterodimer initially identified as the cellular colchicine-binding protein that forms microtubules upon polymerization and interacts with many regulatory cellular proteins (Figure 1). Thereby colchicine inhibits cell migration and cytokine release, particularly by white blood cells. Colchicine also modulates superoxide production by leucocytes23 which is in part responsible for the inhibition of neutrophil adhesion, extravasation, and recruitment by altering neutrophil L-selectin expression and 100mg viagra for sale endothelial cell E-selectin distribution, and suppressing the release of the chemotactic leukotriene B4.

Whether all of these effects are secondary to the impact of colchicine on microtubules remains to be determined. Importantly, however, colchicine inhibits the Nod-Like Receptor Protein 3 (NLRP3) inflammasome 100mg viagra for sale (while urate crystals activate i)t,24 thereby suppressing caspase-1 activation and the subsequent release of IL-1β and IL-18. Figure 1). As the NLRP3 inflammasome is expressed 100mg viagra for sale in the myeloid lineage,25 colchicine appears to mainly interfere with neutrophils and monocytes and macrophages, i.e.

The innate immune system that is involved in ACS, rather than the adaptive immune system. Figure 1Molecular effects of colchicine in white blood cells via tubulin and microtubuli as well as Nod-Like Receptor Protein 3 (NLRP3) 100mg viagra for sale inflammasome. Inset left, urate crystals. Inset right, cholesterol crystals (modified from Imazio M, Gaita F.

Heart April 2016 Vol 102 No 8).Figure 1Molecular effects of colchicine in white blood cells via tubulin and microtubuli as well as Nod-Like Receptor Protein 3 (NLRP3) inflammasome 100mg viagra for sale. Inset left, urate crystals. Inset right, cholesterol crystals (modified from Imazio 100mg viagra for sale M, Gaita F. Heart April 2016 Vol 102 No 8).

Colchicine after acute 100mg viagra for sale coronary syndromes?. Should we now use colchicine in the very early phase of ACS as a remedy to reduce MACE?. First of all, colchicine is cheap and, particularly 100mg viagra for sale at the low dose used in COLCOT, relatively well tolerated. Indeed, in the COLCOT trial, gastrointestinal side effects such as nausea and flatulence were quite rare, with 2.4% vs.

1.2% with placebo. Obviously, as any anti-inflammatory drug, 100mg viagra for sale colchicine increases the risk of . Pneumonia was rare, but indeed more common, with 0.9% vs. 0.4% with colchicine and placebo, respectively 100mg viagra for sale.

Should we therefore avoid prescribing colchicine for the elderly who are at risk of pneumonia or provide them with pneumococcal vaccination?. Indeed, acute s may precipitate 100mg viagra for sale myocardial infarction, while influenza, tetanus, and pneumococcal vaccinations do not produce a detectable increase in this risk, but may actually be protective.26 As such, this may be a reasonable precaution in this context.A second question is whether colchicine would be suitable for all ACS patients or only for those with signs of excessive inflammation?. Indeed, not all patients with ACS have signs of inflammation. Typically, out-of-the-blue infarctions are triggered by other stimuli (such as shear stress, pulsatility, spasm, etc.), while in heralded infarction inflammation plays a primary role.10,27 Unfortunatly, CRP or SAA were not assessed in COLCOT and hence a more personalized use of this drug awaits further studies.

Overall, however, the main COLCOT trial and now this important subanalysis open the door for an even more effective treatment of patients 100mg viagra for sale with ACS with remaining inflammatory risk.Conflict of interest. There are no conflicts of interest for this Editorial. However, the 100mg viagra for sale author has received grants for his ACS research from Amgen, AstraZeneca, Eli Lilly, Medtronic, and Sanofi, and honoraria for consulting and lecturing from Amgen and Sanofi.The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. References1Virchow R.

Die Cellularpathologie in ihrer Begründung auf physiologische und 100mg viagra for sale pathologische Gewebelehre A. Berlin. Hirschwald. 1858.2Anitschkow NN.

A history of experimentation on arterial atherosclerosis in animals. In. Lumenthal HT, ed. Cowdry’s Arteriosclerosis.

A Survey of the Problem. Springfield, IL. Charles C Thomas. 1967.

P21–44.3Castelli WP, Anderson K, Wilson PW, Levy D. Lipids and risk of coronary heart disease. The Framingham Study. Ann Epidemiol 1992;2:23–28.4Velasco JA.

After 4S, CARE and LIPID—is evidence-based medicine being practised?. Atherosclerosis 1999;147 Suppl 1:S39–S44.5Witztum JL, Steinberg D. Role of oxidized low density lipoprotein in atherogenesis. J Clin Invest 1991;88:1785–1792.6Tanner FC, Noll G, Boulanger CM, Lüscher TF.

Oxidized low density lipoproteins inhibit relaxations of porcine coronary arteries. Role of scavenger receptor and endothelium-derived nitric oxide. Circulation 1991;83:2012–2020.7Lüscher TF, Landmesser U, von Eckardstein A, Fogelman AM. High-density lipoprotein.

Vascular protective effects, dysfunction, and potential as therapeutic target. Circ Res 2014;114:171–182.8Speer T, Rohrer L, Blyszczuk P, Shroff R, Kuschnerus K, Kränkel N, Kania G, Zewinger S, Akhmedov A, Shi Y, Martin T, Perisa D, Winnik S, Müller MF, Sester U, Wernicke G, Jung A, Gutteck U, Eriksson U, Geisel J, Deanfield J, von Eckardstein A, Lüscher TF, Fliser D, Bahlmann FH, Landmesser U. Abnormal high-density lipoprotein induces endothelial dysfunction via activation of Toll-like receptor-2. Immunity 2013;38:754–768.9Libby P, Loscalzo J, Ridker PM, Farkouh ME, Hsue PY, Fuster V, Hasan AA,, Amar S.

Inflammation, immunity, and in atherothrombosis. JACC Review Topic of the Week. J Am Coll Cardiol 2018;72:2071–2081.10Maier W., Altwegg LA, Corti R, Gay S, Hersberger M, Maly FE, Sutsch G, Roffi M, Neidhart M, Eberli FR, Tanner FC, Gobbi S, von Eckardstein A, Luscher TF. Inflammatory markers at the site of ruptured plaque in acute myocardial infarction.

Locally increased interleukin-6 and serum amyloid A but decreased C-reactive protein. Circulation 2005;111:1355–1361.11Liuzzo G, Biasucci LM, Gallimore JR, Grillo RL, Rebuzzi AG, Pepys MB, Maseri A. The prognostic value of C-reactive protein and serum amyloid A protein in severe unstable angina. N Engl J Med 1994;331:417–424.12Ridker PM, Hennekens CH, Buring JE, Rifai N.

C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med 2000;342:836–843.13Ridker PM, Danielson E, Fonseca FA, Genest J, Gotto AMJr, Kastelein JJ, Koenig W, Libby P, Lorenzatti AJ, MacFadyen JG, Nordestgaard BG, Shepherd J, Willerson JT, Glynn RJ. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008;359:2195–2207.14Wyss CA, Neidhart M, Altwegg L, Spanaus KS, Yonekawa K, Wischnewsky MB, Corti R, Kucher N, Roffi M, Eberli FR, Amann-Vesti B, Gay S, von Eckardstein A, Lüscher TF, Maier W.

Cellular actors, Toll-like receptors, and local cytokine profile in acute coronary syndromes. Eur Heart J 2010;31:1457–1469.15Heusch G, Gersh BJ. The pathophysiology of acute myocardial infarction and strategies of protection beyond reperfusion. A continual challenge.

Eur Heart J 2017;38:774–784.16Westman PC, Lipinski MJ, Luger D, Waksman R, Bonow RO, Wu E, Epstein SE. Inflammation as a driver of adverse left ventricular remodeling after acute myocardial infarction. J Am Coll Cardiol 2016;67:2050–2060.17Ridker PM, Everett BM, Thuren T, MacFadyen JG, Chang WH, Ballantyne C, Fonseca F, Nicolau J, Koenig W, Anker SD, Kastelein JJP, Cornel JH, Pais P, Pella D, Genest J, Cifkova R, Lorenzatti A, Forster T, Kobalava Z, Vida-Simiti L, Flather M, Shimokawa H, Ogawa H, Dellborg M, Rossi PRF, Troquay RPT, Libby P, Glynn RJ. Antiinflammatory therapy with canakinumab for atherosclerotic disease.

N Engl J Med 2017;377:1119–1131.18Ridker PM, MacFadyen JG, Everett BM, Libby P, Thuren T, Glynn RJ. Relationship of C-reactive protein reduction to cardiovascular event reduction following treatment with canakinumab. A secondary analysis from the CANTOS randomised controlled trial. Lancet 2018;391:319–328.19Ridker PM, MacFadyen JG, Thuren T, Everett BM, Libby P, Glynn RJ.

Effect of interleukin-1β inhibition with canakinumab on incident lung cancer in patients with atherosclerosis. Exploratory results from a randomised, double-blind, placebo-controlled trial. Lancet 2017;390:1833–1842.20Tardif JC, Kouz S, Waters DD, Bertrand OF, Diaz R, Maggioni AP, Pinto FJ, Ibrahim R, Gamra H, Kiwan GS, Berry C, López-Sendón J, Ostadal P, Koenig W, Angoulvant D, Grégoire JC, Lavoie MA, Dubé MP, Rhainds D, Provencher M, Blondeau L, Orfanos A, L’Allier PL, Guertin MC, Roubille F. Efficacy and safety of low-dose colchicine after myocardial infarction.

N Engl J Med 2019;381:2497–2505.21Bouabdallaoui N, Tardif JC, Waters DD, Pinto FJ, Maggioni AP, Diaz R, Berry C, Koenig W, Lopez-Sendon J, Gamra H, Kiwan GS, Blondeau L, Orfanos A, Ibrahim R, Grégoire JC, Dubé MP, Samuel M, Morel O, Lim P, Bertrand OF, Kouz S, Guertin MC, L’Allier PL, Roubille F. Time-to-treatment initiation of colchicine and cardiovascular outcomes after myocardial infarction in the Colchicine Cardiovascular Outcomes Trial (COLCOT). Eur Heart J 2020;41:4092–4099.22Slobodnick A, Shah B, Krasnokutsky S, Pillinger MH. Update on colchicine, 2017.

Rheumatology 2018;57(suppl_1):i4–i11.23Chia EW, Grainger R, Harper JL. Colchicine suppresses neutrophil superoxide production in a murine model of gouty arthritis. A rationale for use of low‐dose colchicine. Br J Pharmacol 2009;153:1288–1295.24Wiendels NJ, Knuistingh Neven A, Rosendaal FR, Spinhoven P, Zitman FG, Assendelft WJ, Ferrari MD.

Chronic frequent headache in the general population. Prevalence and associated factors. Cephalalgia 2006;26:1434–1442.25Mühlhauser I, Sawicki PT, Blank M, Overmann H, Bender R, Berger M. Prognosis of persons with type 1 diabetes on intensified insulin therapy in relation to nephropathy.

J Intern Med 2000;248:333–341.26Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of myocardial infarction and stroke after acute or vaccination. N Engl J Med 2004;351:2611–2618.27Liuzzo G, Biasucci LM, Gallimore JR, Caligiuri G, Buffon A, Rebuzzi AG, Pepys MB, Maseri A. Enhanced inflammatory response in patients with preinfarction unstable angina.

J Am Coll Cardiol 1999;34:1696–1703. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020.

For permissions, please email. Journals.permissions@oup.com.The Green Lane Cardiovascular Research Unit and The Green lane Coordinating Centre in Auckland New ZealandThe Green Lane Cardiovascular Research Unit (CVRU) was formed when Harvey White returned to Green Lane Hospital, Auckland, New Zealand from Boston in 1984 where he was a research fellow at the Brigham and Women’s Hospital. While in Boston, he somehow gained the ‘gene’ for research and writing. Green Lane was the hospital where Sir Brian Barrett-Boyes and many colleagues had performed pioneering homograft aortic valve replacements and developed techniques of hypothermia for operating on babies with congenital heart disease.

There was a focus on high quality clinical care and research.The mission of the CVRU was ‘to do research for improving patient care throughout the world’. The unit began research for three reasons. To improve patient care, to improve science, and to have fun. From the beginning, the unit undertook both local and international collaborative trials.

Local trials were very important. Between 1987 and 1989, there were three major publications from local trials. One in 1987 was in Circulation on ‘Left ventricular end-systolic volume as the major determinant of survival after recovery from myocardial infarction’1 which Dr Eugene Braunwald has called one of the greatest advancements in post-MI management (Braunwald ACC 2013). And two were in the New England Journal of Medicine on thrombolysis and left ventricular function with comparison of streptokinase with placebo, and streptokinase with TPA.2,3It was very clear from the beginning that to make a difference to patient care, large numbers of patients (1000 s) would be needed, to have the statistical power to show benefits and to be able to assess harm.

The only way of doing that was to collaborate, collaborate, and collaborate.International collaboration was first with Australia with Dr Phil Aylward. Phil is an outstanding clinician who brings enormous clinical experience to steering committees in the design and practical undertaking of trials and played a major part in the HERO (Hirulog Early Reperfusion/Occlusion) Trials. And secondly, with Dr Andrew Tonkin and Dr John Simes, also from Australia, on the LIPID (Long-Term Intervention With Pravastatin in Ischaemic Disease) group—a trial showing that pravastatin reduced total mortality in patients with previous myocardial infarction or unstable angina.4 New Zealand contributed over 3000 patients and the collaboration continues with over 20 years follow-up and over 60 publications. The group also published the first study on prevention of stroke subtypes with statin therapy.5In 1988, an international trial branch was formed as part of CVRU to participate in International trials including the ISIS and Gusto trials.

This was initially led by Maggie Scott, former charge nurse of the CCU at Green Lane Hospital. Maggie also coordinated the world-wide HERO-2 trial with 15 000 patients in 27 countries comparing bivalirudin with unfractionated heparin following fibrinolytic therapy6 (Figure 1). Figure 1The Cardiovascular Research Unit (CVRU) in 1992.Figure 1The Cardiovascular Research Unit (CVRU) in 1992.In 2003, an Academic Research Organisation (ARO) named Green Lane Coordinating Centre Limited (GLCC) was formed offsite from Green Lane Hospital. Olga Bucan from Slovenia was the Director and coordinated the STabilisation of Atherosclerotic plaque By Initiation of darapLadib TherapY (STABILITY) Trial with 15 000 patients in 38 countries.7Dr John French joined as a Senior Cardiologist and Researcher in 1992.

John is an enormously hard worker and has numerous publications on coronary flow, LV function, and survival as well as a seminal paper on the importance of factor V Leiden in young patients who had had an MI with normal coronary arteries.8 John left for Australia in 2003 but still closely collaborates on trials and registries.Dr Cheuk-Kit Wong joined CVRU in 1999 and published 25 papers on ECGs from the HERO ECG core laboratory including the first study to show that Q waves on an ECG are more important than door to reperfusion time for prognosis.9The CVRU is now based at Auckland City Hospital as part of the Green Lane Cardiovascular Department. The research unit continues to deliver excellent clinical trial management. A team of investigators, nurses, and administrators support the current trials which include a mix of international academic and pharmaceutical trials as well as local investigators with national and Auckland Hospital based studies (Figure 2 Group). Figure 2The Cardiovascular Research Unit (CVRU) in 2020.

Standing from L to R. Dr Jithendra Somaratne, Prof Harvey White, Dr Jocelyne Benatar, Prof Ralph Stewart. Sitting from L to R. Michelle D’Souza, Leah Howell, Cathrine Patten, and Diana Gatland.Figure 2The Cardiovascular Research Unit (CVRU) in 2020.

Standing from L to R. Dr Jithendra Somaratne, Prof Harvey White, Dr Jocelyne Benatar, Prof Ralph Stewart. Sitting from L to R. Michelle D’Souza, Leah Howell, Cathrine Patten, and Diana Gatland.Dr Jocelyne Benatar joined in 2000 and has done a number of studies assessing the effects of dairy food on cardiovascular disease and diet on cardiometabolic syndrome.10 She continues as the principal and co-investigator for a number of nutritional, diabetes, rehabilitation, and cardiovascular trials.Dr Ralph Stewart joined CVRU in 1999 and GLCC in 2003 and has led numerous trials including the recent New Zealand Oxygen Study (Stewart ESC 2019).

He along with Ivor Gerber reported the relationship between NT-proBNP levels and the prognosis of patients with aortic valve disease.11Research nurses have been a very important and an integral part of the CVRU and the development of a career pathway and work/life balance has been a primary focus. The CVRU was one of the first to employ research nurses. The first research nurse was Barbara Williams who had been in charge of the CCU at Green Lane Hospital. Barbara led a study on consent in patient with acute STEMI published in the Lancet.12 Mary Denton was CVRU’s first nurse manager.

Today, nurse co-ordinator Cathrine Patten manages the current trials.Caroline Alsweiler who was a Senior Clinical Research Associate and Clinical Trial Manager became Director of GLCC in 2014. The GLCC works closely with a core group of investigators in New Zealand, Australia, Singapore, Hong Kong, Malaysia, Thailand, Korea, and the Philippines to deliver high quality data (Figure 3), The Mission statement is ‘to improve the health and quality of life of people throughout the world through innovative clinical research’. Together with support from national and international academia, they are dedicated to achieving the highest possible standard in clinical research while maintaining well-established relationships with investigators both nationally and internationally, achieving quick turnaround times for completion of regulatory documents, and ensuring integrity of research data. The GLCC has been involved with over 70 international clinical trials from Phases II–IV.

Figure 3Members of the Green Lane Coordinating Centre (GLCC) in 2019.Figure 3Members of the Green Lane Coordinating Centre (GLCC) in 2019.The CVRU and GLCC have received many acknowledgements and awards. It has to be strongly stressed that these and publications have been a team effort. In 1998, Harvey was awarded the Prince Mahidol Award for Medicine by the King of Thailand for introducing aspirin and fibrinolytic therapy in 27 developing countries, including China (Figure 4). This award is considered the Nobel Prize of the East and is given for introducing treatments rather than being the first to discover something.

Harvey was bestowed a Matai (Chief) title in Samoa in 1994 with a title of ‘La’auli’ the highest peak in the land for his work treating patients as well as working with WHO in Samoa. Figure 4Harvey receiving the Prince Mahidol Award from the King of Thailand.Figure 4Harvey receiving the Prince Mahidol Award from the King of Thailand.In 2020, the work from CVRU and GLCC was ranked no. 5 in the world across all branches of medicine for publication of RCT-related articles in high-impact-factor medical journals over the past five decades and with the highest collaboration index.13The CVRU and GLCC continue to be very productive with over 20 ongoing trials. The special research interests include management of acute coronary syndromes, antithrombotic management of acute coronary syndromes and atrial fibrillation, biomarkers, secondary prevention of cardiovascular disease, management of cardiovascular disease in the elderly, diabetes, nutrition, rehabilitation, frailty, dyslipidaemia, and registry studies.Over 1000 peer-reviewed manuscripts have been published.

Contributions of the two organizations to multicentre trials have helped develop the evidence base for guidelines for the practice of clinical cardiology. These include the role of troponins in ACS,14 the importance of 0.5 mm ST depression for prognosis in patients with non-STEMI,15 elderly patients should not be denied fibrinolytic therapy,16 the risks of switching antithrombotic therapy,17 the BARC bleeding definition,18 and the Universal definition of MI defining the five types of MI.19Relationships have been very important and one of the wonderful things about collaborating in International trials is meeting and making friends with the most amazing people from the ISIS, Gusto, TIMI, Duke, Leuven, Uppsala, Vigour, ECLA, OASIS, New York University, Montreal, SAMHRI, ODYSSEY, and Cleveland Clinic groups etc. (Figure 5). Figure 5Members of the Vigour organization at the Uppsala Research Centre from Duke USA, Canada, Sweden, and New Zealand in Uppsala in 2010.Figure 5Members of the Vigour organization at the Uppsala Research Centre from Duke USA, Canada, Sweden, and New Zealand in Uppsala in 2010.A Māori proverb (of the indigenous people of New Zealand) says:‘He aha te mea nui o te aoWhat is the most important thing in the world?.

He tangata, he tangata, he tangataIt is the people, it is the people, it is the people’The many people in the two Green Lane organizations (CVRU and GLCC) have had fun, perhaps contributions have been made to science and patient care has also been improved. AcknowledgementsMichelle D'Souza provided editorial and secretarial assistance in the preparation of the manuscript and was funded by The Green Lane Research and Educational Fund (GLREF), Auckland City Hospital. Dr White gratefully thanks the GLREF for support as the John Neutze Fellow. We would like to thank cardiologists and cardiac surgeons and nurses throughout New Zealand and the world, and patients who have taken part in the clinical trials.Conflict of interest.

H.D.W. Has received grant support paid to the institution and fees for serving on a steering committee from Sanofi-Aventis and Regeneron Pharmaceuticals, for the HEART-FID study from American Regent. For the dal-GenE study from DalCor Pharma UK Inc., for the AEGIS-II study from CSL Behring, for the SCORED trial and the SOLOIST-WHF trial from Sanofi-Aventis Australia Pty Ltd, and for the CLEAR Outcomes Study from Esperion Therapeutics Inc. He was on an Advisory Board for Genentech, Inc.

And received lecture fees from AstraZeneca outside the submitted work. ReferencesReferences are available as supplementary material at European Heart Journal online. Published on behalf of the European Society of Cardiology. All rights reserved.

© The Author(s) 2020. For permissions, please email. Journals.permissions@oup.com..